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PRACTICAL DIETETICS 



WITH SPECIAL REFERENCE TO 
DIET IN DISEASE 



BY 

W. GILMAN THOMPSON, M. D. 

PROFESSOR OF MEDICINE IN THE CORNELL UNIVERSITY MEDICAL COLLEGE 

IN NEW YORK CITY 

VISITING PHYSICIAN TO THE PRESBYTERIAN AND BELLEVUE HOSPITALS 



Good diet with wisdom best comforteth men " 

Tusser (1520) 



SECOND. EDITION, ENLARGED AND THOROUGHLY REVISED 



NEW YORK 
D. APPLE TON AND COMPANY 

1902 



T?/T}2/(o 



THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

MAY. 24 1902 

Copyright entry 

CLASS ^XXc No. 

COPY B. 



Copyright 1895, 1902 
By D. APPLETON AND COMPANY 



Published May, 1902 



PREFACE TO THE SECOND EDITION 



The present edition of this work has been prepared to meet 
the demands of an increasing interest in the practical application 
of dietetic principles. The book has-been revised throughout, in 
part rewritten, and over thirty .pages of new matter have been added. 
The writer has again availed rTimself of the exceedingly valuable 
contributions to scientific dietetics published by the United States 
Department of Agriculture, comprising the results of food studies 
conducted at the various experiment stations in all parts of the 
country, and illustrating particularly the economic value of different 
dietaries. The sections on Diet in Disease have also been enlarged 
and, as in the previous edition, developed with special reference 
to their practical application for the sick. 

W. G. T. 



INTRODUCTION TO THE FIRST EDITION 



The subject of the dietetic treatment of disease has not received 
the attention in medical literature which it deserves, and it is to 
be regretted that in the curriculum of medical colleges it is usually 
either omitted or is disposed of in one or two brief lectures at 
the end of a course in general therapeutics. Upon examining the 
standard treatises upon the Theory and Practice of Medicine, as 
well as monographs upon important diseases, such as those of the 
circulation, nervous system, and skin, one cannot fail to be im- 
pressed with the meagre notice given to the necessity of feeding 
patients properly, and the subject is usually dismissed with such 
brief and indefinite phrases as " The value of nutritious diet re- 
quires mere mention," " A proper but restricted diet is recom- 
mended," and favourite, if not convincing, expressions are, " The 
patient should be carefully fed," and " General dietetic treatment 
is of primary importance." With such vague directions the diet- 
ing must indeed be very " general." 

In many excellent works upon food and dietetics the space de- 
voted to the practical application of dietetics to disease is compara- 
tively insignificant, and much less emphasis is given to this matter 
in hospitals and in the training of nurses than is demanded in the 
interests of medical science. 

A writer of wide experience in practical dietetics, Mrs. E. H. 
Richards, says : " At present there are comparatively few persons 
who are called upon to feed the sick to whom a glass of milk or 
a pound of beef represent any definite amount of food materials. 
Still fewer who can tell how much food value a glass of lemon 
jelly or wine whey represents, and yet the adult patient is de- 
pendent upon the attendant even more than the week-old infant 
for the requisite nutrition." 



VI PREFACE 

The present volume has been prepared with the view of in some 
measure making good such deficiencies by furnishing a text-book 
in which the practitioner of medicine may find detailed the appro- 
priate diet for each disease which is at all influenced by right 
feeding. 

Quite as much depends upon the suitable preparation of food 
as upon the selection and limitation of the food itself, and it has 
therefore been thought advisable to include a general account of 
the composition and uses of foods, and the changes which may 
be produced in them by cooking and other processes. In this first 
portion of the work, however, the practical application of such 
knowledge to the feeding of the sick has been constantly empha- 
sised rather than unnecessary scientific detail. 

The reader will also find a discussion of representative hospital 
dietaries, the official dietaries of Government institutions, and sec- 
tions upon the proper feeding of infants and children. Numerous 
cross references and a complete index have been added to avoid 
undue repetition. 

Bennett wrote, as long ago as 1858 : " Of all the means of cure 
at our disposal, attention to the quantity and quality of the ingesta 
is by far the most powerful." While fully concurring in this view, 
that appropriate dieting is often more needed than medication, I 
distinctly disclaim the advocacy of any special dietetic system as 
a cure-all, as well as the specific influence of any one food in the 
general treatment of disease. It cannot be expected that the ex- 
perience of a single individual should cover so extensive a ground 
as that which embraces the relative advantages of all foods, and I 
have therefore impartially introduced the views of others, especially 
where, as in such diseases as gout, diabetes, and obesity, opposing 
dietetic theories are held by clinicians of extensive experience and 
authority. Due acknowledgment of these references is made in the 
text, but the admirable researches upon foods of our own Govern- 
ment, found in the published reports of the Department of Agricul- 
ture and of the Commission to the Paris Universal Exposition of 
1889, and at the Columbian Exposition of 1893, are especially to 
be commended. 

W. Gilman Thompson. 



CONTENTS 



Introduction 



PAGE 

iii 



PART I 



FOODS AND FOOD PREPARATIONS 

Elementary composition of foods . 
Food classification .... 
Force production. Energy from food 
Force-producing value of the different classes of foods 

I. Water . . . . 

II. Salts 

III. Proteids, carbohydrates, and fats 
Stimulating foods .... 
Economic value of foods . 
Nutrition ..... 

Animal and vegetable foods compared 
Vegetarianism .... 
The classes of foods 

I. Water 

Uses of water in the body . 
Purity of water . ... 

Varieties of drinking water 

Hard and soft water 

Rain water .... 

River water .... 

Distilled water 

Filtered water 

Boiled water .... 
Special dietetic uses of water 
Excess of water 
Deprivation of water. Water starvation 

Thirst 

Temperature of drinking water . 

II. Salts 

Variety of salts .... 
Uses of salts in foods 
Excess of salt .... 
Deprivation of salt . . • . 

Sodium salts .... 

Potassium salts 

Calcium salts .... 

Phosphorus .... 

Sulphur ..... 

Iron ...... 

Vegetable acids 



4 
7 

18 
18 
19 
19 
23 
24 
29 
29 
35 
37 
37 
38 
38 
39 
39 
39 
40 
40 
40 
41 
4i 
42 
43 
43 
44 
45 
45 
45 
45 
46 
46 
47 
47 
48 
48 
48 
48 



Vlll 



CONTENTS 



III. Animal foods. 

Milk 

Exclusive milk diet 

" Milk cure " ... 

Chemical composition of milk 

Fat 

Lactose .... 

Casein and albumin 
Varieties of milk . 

Cow's milk .... 

Human milk 

Drugs in human milk 
Goat's milk 
Ass's milk .... 

Mare's milk 
Milk analysis .... 

Reaction, colour, taste, odour 
Estimation of solids . 
Estimation of fat 
Estimation of lactose . 
Estimation of albuminoids . 
Milk adulteration and impurities 
Addition of water 
Addition of colouring matter 
Addition of preservatives 
Addition of thickening substances 
Milk contamination by the cow's food 
Contamination by the cow's condition 
Contamination by the cow's disease germs 
Contamination by extraneous disease germs 
Souring and decomposition 
Absorption of bad odours . 
Prophylaxis against milk infection 
Uses of milk ..... 

Milk digestion .... 

Normal (Rennin) 

Abnormal ..... 

. Adaptation of milk for the sick 

Methods of altering the taste of milk 
Methods of improving the digestibility of milk 
Skimming ..... 

Boiling ...... 

Dilution with water 

Dilution with alkaline and aerated waters 
Dilution with amylaceous foods 
Addition of alkalies, acid, and other substances 
Methods of predigestion of milk . 
Peptonised milk 
Pancreatinised milk 
Koumiss . 
" Koumiss cure " 
Kefir 

Matzoon or zoolak . 
Methods of sterilisation and preservation of milk 
Sterilised milk . 
Pasteurised milk 



CONTENTS 












ix 


PAGE 


" Humanised milk "... .88 


Modified milk. Milk laboratories 












. 88 


Milk derivatives . 












93 


Condensed milk 














• 93 


Cream 














. 94 


Butter 














. 9 6 


Buttermilk 














• 97 


Cheese 














■ 97 


Whey 














. 101 


Eggs .... 














. 101 


Raw eggs. Eggnog. Egg a 


lbumin 












• 103 


The cooking of eggs . 














. 104 


Preservation of eggs 














• 105 


Meats 














. 106 


Consumption of meat . 














. 106 


Composition of meats . 














. 107 


Raw meats . 














. 108 


Digestibility of meats . 














. 108 


Beef .... 














. 109 


Beef preparations for the sic' 


c 












. no 


Solid meat preparations 














III 


Scraped meat 














. Ill 


Beef meal 














III 


Beef jelly 














. Ill 


Beef extracts . 














112 


Beef blood 














112 


Beef peptonoids 














113 


Fluid meat preparations. 
















Beef juice 














114 


Beef tea . 














114 


Bouillon 














Il6 


Beef broth 














Il6 


Beef extracts . 














117 


Summary 














Il8 


Various meats 














119 


Beef tongue 














119 


Veal 














119 


Mutton 














119 


Lamb 














119 


Venison 














119 


Pork .... 














120 


Ham and Bacon 














120 


Fowl 














121 


Game ..... 














121 


Animal viscera 














121 


Sweetbread 














121 


Tripe, liver, kidneys, brains 


, blood 












122 


Isinglass, gelatin . 














122 


Jellies .... 














123 


Fish 














124 


Crustaceans 














125 


Shellfish — oysters, clams, n 


lussels 












126 


Vegetable foods 














127 


Sugars .... 














127 


Sugars and the urine 














128 


Cane sugar, saccharose . 














129 



X 



CONTENTS 



Caramel 

Molasses and treacle 
Grape sugar, glucose 
Milk sugar, lactose 
Mannite and levulose 
Honey . 
Saccharin 
Cereals and other starchy food 
Starchy foods in general 
Bread making 

Structure of the wheat kernel 

Bran . 

Gluten 

Composition of bread 

Bread baking 

Development of carbonic-acid gas 

Yeast, leaven 

Baking powders 

Aerated bread 
Varieties of bread stuffs 

Wheaten flour and bread 

Whole-meal bread 

Gluten bread 

Rye bread . 

Biscuits, pastry, puddings, etc. 
Prepared farinaceous foods 

Buckwheat 

Rye . 

Corn 

Rice . 

Barley 

Oatmeal 

Arrowroot 

Tapioca, cassava 

Sago 

Iceland moss 
Starchy foods for children 
Diastase, malt extracts, etc. 
Vegetable food 

Legumes, peas, beans, lentil 
Roots and tubers . 

Potatoes 

Beets 

Succulent tubers 
Green vegetables . 

Cabbages, etc. 

Tomatoes, etc. . 
Fruits 

Composition of fruits 

Uses and properties of fruits 

Fruit ripening . 

Fruit poisoning 

When to eat fruit 
Fruit soups . 
Dried fruits . 
Digestibility of fruits 



CONTENTS 



XI 



Varieties of fruits 

Lemons, limes, shaddocks 
Oranges .... 
Apples .... 
Pears, peaches, etc. . 
Bananas .... 
Banana flour for invalids . 
Grapes .... 
Plums, prunes . 
Berries, strawberries, etc. . 
Melons .... 
Figs and dates . 

Fungi 

Poisonous fungi . 
Lichen ..... 

Nuts 

Fats and oils 

Uses of fats .... 

Digestibility of fats . 

Animal fats . . . 

Bone marrow .... 

Vegetable fats and oils 

Olive oil . 

Dietetic uses of fats and oils . 

Diseases in which fats are beneficial 

Diseases in which fats are forbidden 

Glycerin . . . 

Cod-liver oil . 

Chemical and physical properties 
Dosage .... 

Methods of administration . 
Substitutes .... 
Uses . . . . 



179 
179 
180 
180 
181 
182 
183 
184 
185 
186 

187 
188 
188 
189 
190 
190 
192 
192 
194 

195 
196 
197 
197 
198 
199 

199 
199 
199 
199 
200 
201 
203 
203 



PART II 



STIMULANTS, BEVERAGES, CONDIMENTS 



Stimulants and beverages 












205 


Alkaline and mineral waters, effervescing waters 










207 


Tannin ........ 










210 


Tea ....... 












211 


Physiological and therapeutic action of tea 












212 


Adulteration of tea .... 












215 


Coffee ....... 












215 


Physiological action of coffee 












217 


Adulteration of coffee 












219 


Relative value of coffee and tea 












220 


Cocoa ....... 












221 


Cacao butter 












222 


Chocolate .... 












223 


Kola . . 












224 


Alcohol ....... 












225 


General discussion of the value of alcohol 












■1-5 


Physiological action .... 












228 



Xll 




CONTENTS 














PAGE 


I. As a food 228 


II. As a stimulant .... 






» 


229 


III. Action upon the muscles . 










230 


IV. Action upon the temperature 












230 


V. Action as a diuretic 












231 


VI. Action upon mucous membranes 












231 


VII. Action upon gastric digestion . 












231 


VIII. Alcohol absorption 












232 


IX. Alcohol elimination . i^l 












233 


X. Alcohol poisoning 














233 


XI. Alcohol and climate 


. 












233 


Clinical uses of alcohol 














234 


1. As a tonic . 














234 


2. As a vascular and cardiac stimulant 












235 


3. Use in nervous diseases 












236 


4. Use in fevers .... 












236 


Proper time for giving alcohol . 












237 


Selection of proper alcoholic beverage 












238 


Malt liquors ...... 












239 


Beer . 
















239 


Beer brewing . 
















240 


Ale 
















241 


Porter, stout 
Wine 
















241 

241 


Composition 
















241 


General properties 
















242 


White wines . * 
















243 


Red wines . 
















244 


Varieties of wines 
















245 


I. Strong dry wines 














245 


II. Strong sweet wines 














246 


III. Aromatic wines 














246 


IV. Acid wines 














246 


V. Sparkling wines 














246 


VI. " Perfect " wines 














248 


VII. Rough wines . 














249 


Liquors .... 














250 


Brandy, whisky, gin, rum 














250 


Therapeutic uses of liquors 














251 


Adulteration of liquors and 


wines 












251 


Liqueurs 














252 


Cider .... 














253 


Condiments and spices . 














253 


Properties, uses, harmful effects . 












253 


Varieties 
















254 



PART III 



COOKING. — FOOD PREPARATION AND PRESERVATION. — THE QUANTITY OF FOOD 

REQUIRED 

Cooking . . . . . . . . . . . . . 259 

Object of cooking food 259 

Varieties of cooking .......... 260 

1. Boiling ........... 261 



CONTENTS 



Xlll 



2. Stewing 

3. Roasting 

4. Grilling 

5. Frying 

6. Braising 

7. Baking 

8. Steaming 
Soups 

Cooking of fish 
Cooking of vegetables 

Food concentration. — Condensed food 

Drying, desiccation, extracts 
Diet of concentrated foods 
Food preservation 

I. Drying 

II. Smoking 

III. Salting 

IV. Freezing 

V. Refrigeration 

VI. Sterilisation 
VII Exclusion of air. — Canning 
VIII. Antiseptic and preservative substances 

Substitutes for food 
Quantity of food required 
Starvation and inanition 

Voluntary fasting 

Symptoms of starvation 

Treatment after starvation 

Famine 
Improperly balanced ingredients of diet 



263 
264 
264 
267 
268 
268 
268 
268 
269 
269 
270 
270 
272 
274 
274 
275 
275 
276 
276 
277 
278 
281 
282 
283 
297 
298 
300 
303 
304 
304 



PART IV 



FOODS REQUIRED FOR SPECIAL CONDITIONS 



Age and food 

Food in childhood 

Food in adult life 

Food in old age . 
Individual size and food 
Body weight and food 
Sex and food . 
Diet and heredity . 
Diet and race 
Climate and season and food 



306 
306 
307 
308 

3ii 
312 

313 
314 
314 
320 



PART V 

FOOD DIGESTION. — CONDITIONS WHICH ESPECIALLY AFFECT DIGESTION 

Hours for meals and order of taking food 323 

Appetite . .327 

Abnormal cravings ...... ... 328 

Variety in diet 329 



XIV 



CONTENTS 



The nervous system and digestion 
Circulation and digestion 
Temperature and digestion 
Exercise and digestion . 
Rest and sleep and digestion . 

Sleep in relation to meals 
Mental emotion and digestion 
Food in the mouth 
Food in the stomach 

Quantity of gastric juice 

Secretion of the gastric juice 

Hydrochloric acid 

Pepsin, albumoses, peptones 
Peristalsis 

Duration of gastric digestion of different 
Digestion of proteids in the stomach 
Abnormalities of gastric digestion 

Hypersecretion . 

Hyperacidity 

Absence of hydrochloric acid 

Pyrosis 
Food in the intestine 

Pancreatic juice . 

Bile .... 

Digestion of fats 

Intestinal gases . 
Artificial digestion . 

Predigestion of starches 

Predigestion of proteids 
Food absorption 
Elimination of food waste 
The urine and food 
Tobacco and food . 
Food equivalents 



foods 



33i 
332 
333 
336 
337 
338 
340 
340 
34i 
342 
342 
343 
344 
346 
346 
348 
349 
349 
349 
350 
35o 
350 
350 
35i 
35i 
352 
352 
353 
354 
358 
359 
360 
360 
361 



PART VI 



THE GENERAL RELATION OF FOOD TO SPECIAL DISEASES. 
ARE CAUSED BY DIETETIC ERRORS 



-DISEASES WHICH 



The general relation of food to special diseases .... 
Diseases caused by dietetic errors ....... 

I. Insufficient food . . . . . . . 

II. Overeating and overdrinking ...... 

• III. Food in itself wholesome, but which is injurious because 
ingredients are not properly balanced .... 

IV. Food containing parasites or their embryos 

Intestinal worms ......... 

Trichiniasis . . . . . . . . . 

V. Food containing ptomaines ....... 

Poisoning by meat or game ....... 

Poisoning by milk, cream, ice cream, and cheese 

Poisoning by shellfish and fish 

VI. Food containing other poisons than ptomaines 

Grain poisoning ......... 



the 



363 
365 
366 
366 

368 
368 
369 
370 
374 
375 
377 
378 
379 
380 



CONTENTS 



XV 



Ergotism 

Lathyrism 

Pellagra 

VII. Food adulteration 
Pigments 
Salicylic acid 
Tin and lead poisoning 

VIII. Food containing micro-organisms 
Milk infection ...... 

Tubercular infection through milk and meat 
Typhoid and cholera infection . 
Infection through oysters 

Diphtheria and scarlatina . 

Foot-and-mouth disease .... 
Food infection through flies 

IX. Idiosyncrasies in regard to food . 

X. Alcohol poisoning. Alcoholism . 
Delirium tremens ..... 



380 
380 
381 
38i 
383 
384 
384 
385 
385 
386 



390 
390 
390 
39i 
392 
395 



PART VII 



ADMINISTRATION OF FOOD FOR THE SICK 



Methods of feeding the sick 
General rules 

The appetite 

Regularity in feeding 

Quantity of food 

Details of serving food 

Feeding helpless patients 

Sleep and feeding . 

Cleansing the mouth 

Disinfection of utensils 

Feeding unconscious patients 
Nutrient enemata 

Conditions necessitating rectal feeding 

Hunger and thirst during rectal feeding 

Method of injection 

Aids to retention 

Temperature of injections 

Number of injections 

Care of the rectum . 

Opium in enemata . 

Substances available for rectal feeding 

Prescriptions for food enemata 
Food suppositories 
Inunction foods . 
Intravascular feeding 
Hypodermic feeding 
Medicines and food 
Diet-kitchen outfit . 
Trained purveyors of food 



397 

397 
397 
398 
398 
398 
400 
401 
401 
401 
402 
403 
403 
404 
404 
406 
406 
406 
406 
407 
408 
410 
410 
410 
411 
411 
411 
414 
414 



XVI CONTENTS • 

PART VIII 

DIET IN DISEASE. — DIET IN INFECTIOUS DISEASES 

PAGE 

Diet in fever in general . . . . . . . . . 415 

Pathological physiology of fever ........ 415 

Dietetic treatment . 4^ 

Beverages in fevers .......... 420 

Alcohol as a food in fevers ......... 421 

Diet in convalescence from fevers ....... 423 

Typhoid fever ............ 425 

Pathological physiology ......... 425 

Dietetic treatment 426 

Milk diet .426 

Substitutes for milk diet ......... 428 

Thirst 430 

Alcohol ............ 431 

Relation of intestinal antisepsis to diet ...... 432 

Care of the mouth .......... 433 

Convalescence ........... 434 

Rules for feeding atypical cases . . . . . . . . 436 

Typhoid fever in children ......... 437 

Typhus fever ............ 437 

Smallpox ............ 438 

Scarlet fever ............ 438 

Measles ............. 439 

Mumps ............. 440 

Whooping cough ........... 440 

Influenza ............ 440 

Diphtheria ............ 442 

Intubation ............ 442 

Tracheotomy ........... 444 

Post-diphtheritic paralysis ......... 444 

Cerebro-spinal meningitis ......... 444 

Erysipelas ............ 445 

Cholera ............. 446 

Yellow fever 449 

Pyaemia and septicaemia .......... 452 

Malarial fevers . . . . . . . . . . . 453 

Tetanus ............. 453 

Rabies 454 

Tuberculosis . . . . . . . . ... . . 454 

General considerations ......... 455 

Diet in mild cases .......... 460 

Foods allowed in non-active cases without gastric catarrh . . 461 

Diet in advanced cases ......... 462 

Milk diet 463 

Suralimentation ........... 464 

Diet for forced feeding ......... 465 

Aids to dietetic treatment . . 466 

Diet " cures " for phthisis . . 4^7 

DIET IN DISEASES OF THE RESPIRATORY SYSTEM 

Laryngismus stridulus 467 

Tubercular laryngitis .......-.- 468 



CONTENTS 



XV11 



Haemorrhage of the lungs 
Acute capillary bronchitis 
Chronic bronchitis . 
Asthma ..... 
Emphysema .... 
Pneumonia .... 
Broncho-pneumonia 

Broncho-pneumonia in children 
Pleurisy .... 

Empyema .... 



PAGE 
468 
469 
470 
470 

471 
472 

474 

474 
474 
476 



DIET IN DISEASES OF THE CIRCULATORY SYSTEM AND BLOOD 

Diseases of the heart 

Pathological physiology 

Use of fluids .... 

Dietetic treatment 

Cardiac valvular disease in children 

Dietetic treatment of the senile heart 

Angina pectoris . 

Cardiac palpitation 
Arterial sclerosis 
Aneurism 

TufneH's diet 
Anaemia. — Chlorosis 
Pernicious anaemia 



476 
476 

477 
477 
478 
479 
482 
482 
482 
J.82 
483 
484 
489 



DIET IN DISEASES OF THE URINARY SYSTEM 



Modifications in the urine caused by food 
Acute nephritis .... 

Acute nephritis in children . 
Albuminuria. — Functional albuminuria 
Chronic Bright's disease 

Milk diet 

Pyelitis ...... 

Oxaluria ..... 

Calculi, renal and vesical 

Lithaemia. Uric-acid diathesis. — Gravel 

Gonorrhoea ...... 



489 
490 
492 
492 
496 
497 
501 
501 
502 

504 
^06 



DIET IN DISEASES OF THE ALIMENTARY CANAL 



Abnormal dentition 
Catarrhal stomatitis 
Tonsilitis and quinsy 
Dysphagia ..... 
Stricture and carcinoma of the cesophag 
Feeding through a gastric fistula . 
Foreign bodies swallowed 
Indigestion and dyspepsia 

Symptoms . 

^Etiology. Idiosyncrasies . 

Examination of the stomach contents 

Test meals ..... 

Tests for hydrochloric acid . 

Hypersecretion . 



507 
507 
=io8 
508 

509 
510 

510 
5ii 
5ii 
512 

515 
5J5 
517 
519 



XV111 



CONTENTS 



Tests for pepsin and rennin 

Tests for motor power of stomach 

Tests for absorptive power of stomach 
Dietetic treatment of dyspepsia 

Desirable foods .... 

Beverages ..... 

Special systems of treatment 

General rules for dyspeptics 

Rules for special varieties of dyspepsi 

Dyspepsia in children . 
Acute gastric catarrh 

Gastric fever in children 
Chronic gastric catarrh . 

Pathological physiology 

Dietetic treatment 

Milk diet . 

Other diet . 

Convalescence 

Hydrochloric acid 
Chronic gastric catarrh in children 
Dilatation of the stomach. — Gastrectasia 

Lavage 

Massage . . . 

Electricity . 
Vomiting 

Pathological physiology 

Dietetic treatment 
Seasickness 

Vomiting of pregnancy . 
Ulcer of the stomach 
Cancer of the stomach . 



PAGE 

519 
520 

521 
521 
522 
523 
524 
525 
525 
526 

527 
529 
530 
531 
531 
532 
533 
534 
535 
536 
536 
538 
54i 
542 
543 
543 
543 
544 
546 
546 
550 



DIET IN DISEASES OF THE INTESTINES 

Diarrhoea , . 55 2 

Pathological physiology 552 

Dietetic treatment .......... 553 

Diarrhoea in infants and young children ....... 554 

Dietetic causes ........... 554 

Examination of stools ......... 555 

Dietetic treatment .......... 556 

Entero-colitis in infants and children. Summer diarrhoea . . . 557 

Cholera infantum or acute milk infection ...... 558 

Cholera morbus. Acute catarrhal enteritis in adults .... 560 

Chronic enteritis in adults. Chronic intestinal catarrh. Chronic colitis . 561 

Chronic intestinal indigestion in children ...... 562 

Chronic gastro-intestinal catarrh. Chronic entero-colitis. Chronic diar- 
rhoea in children .......■•• 5^3 

Simple atrophy. Marasmus .......•• 564 

Mucous disease. Chronic pseudo-membranous gastro-enteritis. Mem- 
branous enteritis .......-•• 5^5 

Dysentery 566 

Chronic dysentery ........... 567 

Acute intestinal obstruction ......... 567 

Chronic constipation .......... 568 

Physiology ............ 568 



CONTENTS 



XIX 



Pathological physiology 

Dietetic treatment 

Summary of the most useful articles o 

Foods to be avoided . 

Aids to dietetic treatment . 
Constipation in infants and children 

Foods recommended 

Foods forbidden . 
Hemorrhoids 
Appendicitis . 

Causation 

Dietetic treatment 
Acute peritonitis 
Chronic peritonitis 



f diet 



569 
571 
573 
573 
574 
576 
577 
577 
578 
578 
578 
579 
579 
580 



DIET IN DISEASES OF THE LIVER 

Diet in liver diseases in general .... 

" Biliousness " 

Causation ....... 

Dietetic treatment . . . . . 

Directions for eating .... 

Acute catarrhal inflammation of the gall ducts. 

rhal jaundice 

Cirrhosis 

Dietetic treatment of cirrhosis without ascites 
Ascites ....... 

Dietetic treatment of cirrhosis with ascites . 

Fatty liver 

Amyloid liver ...... 

Syphilis of the liver . . 

Abscess of the liver 

Gallstones ....... 

Pathological physiology .... 

Dietetic treatment 

Diet in pancreatic diseases .... 



Angiocholitis. Catar 



580 
580 
580 
58i 

583 

584 
584 
585 
585 
586 
586 
587 
588 
588 
588 
588 
589 
591 



DIET IN DISEASES OF THE NERVOUS SYSTEM 



Neuralgia 

Causation 

Dietetic treatment 
Visceral neuralgia 

Gastralgia . 

Enteralgia . 

Hepatalgia . 
Migraine 
Neurasthenia 

Causation 

General treatment 

The " rest cure " 

Weir Mitchell's diet 

Playfair's diet 

Leyden's diet 

Keating's diet 
Insomnia and disordered sleep 



591 
59i 
592 
593 
594 
595 
595 
595 
597 
597 
598 
600 
602 
602 
603 
603 
605 



XX 



CONTENTS 



Vertigo . 
Chorea . 
Epilepsy 
Beri-beri 

Locomotor ataxia 
Apoplexy- 
Acute insanity. Melancholia. 
Forced feeding 



Primary dementia. Mania 



DIET IN SKIN DISEASES 

Skin diseases which are caused by improper diet 

General principles of dietetic treatment 
Erythema. Urticaria 
Acne .... 
Eczema .... 

Cases due to overeating 

Typical diet for eczema 

Cases due to insufficient food 

Cases due to improper food 
Eczema in nursing infants 
Eczema in children 
Exfoliative dermatitis 
Rosacea 
Psoriasis 
Pruritus 
Furunculosis . 



DISEASES ESPECIALLY INFLUENCED BY DIET 



Obesity (Polysarcia) 
Causation 
Dietetic treatment 
Systems of Banting 

Ebstein 

Oertel 

Schweninger 

Schleicher 

Germain See 

Weir Mitchell 

Yeo 

Duj ardin-Beaumetz 
Meat and hot-water treatment 
System of Bouchard 
System of Chambers 
" Anti-fat " remedies 
Diet for leanness 
Rheumatism, acute 

Chronic 
Arthritis deformans 
Gout 

Causation 

Preventive treatment 

Theory of dietetic treatment 

Diet for the gouty diathesis and chronic gout 

Beverages 



CONTENTS 



XXI 



Diabetes mellitus . 
Causation .... 
Relation to gout and other disea 
Physiological experiments . 
The nervous system and diabetes 
The circulation and diabetes 
Various theories 
Symptoms . 
Course 

Dietetic treatment 
Foods allowed 
Foods forbidden 
Substitutes for bread 
Substitutes for sugar 
Beverages 
Special diets 
Skimmed milk 
Ebstein's diet . 
During' s diet . 
Naunyn's diet . 
Medicinal treatment 
Rhachitis (rickets) . 
Aids to dietetic treatment 
Scurvy . 

Causation 
Hemorrhagic purpura 



654 
655 
656 

657 
661 
661 
661 
663 
666 
668 
673 
675 
675 
679 
680 
682 
682 
682 
683 
683 
684 
685 
688 
688 
688 
692 



DIET IN MISCELLANEOUS DISEASES 

Addison's disease . 
Osteomalacia 
Exophthalmic goitre 
Chronic lead poisoning 

Dietetic treatment 
Dietetic complications arising from associated diseases 



692 
692 
693 
693 
693 
694 



DIET FOR SURGICAL PATIENTS 



Food and anaesthetics 

Diet after anaesthesia 

Surgical operations and injuries 
Laparotomy. Ovariotomy . 
Surgical inflammation. Sepsis 



695 
696 
696 
698 
698 



PART IX 



RATIONS. — DIETARIES 



Army and navy diets 
The U. S. army rations 
U. S. army ration in the field 
U. S. army travel ration 
Garrison ration for ten days 
Foreign army rations . 
Navy rations 



700 
700 
702 
702 
705 
707 
710 



XX11 



CONTENTS 



Diet in prisons .... 

U. S. army prison diet 

New York State Reformatory diet 
Dietetic cures 

Milk cure .... 

Whey cure .... 

Various " cures " 
Kneipp system 

Fruit cures .... 

Grape cure .... 

Meat and hot-water cure 

Dry cure .... 

Schroth's method 
Athletic training 

Dietary of the Yale boat crew 

Dietary of the Yale football team 
Diet and occupation 

Brain workers 

Commercial life . 

Travel 
Diet in pregnancy 
Diet for puerperal women 
Selection of a wet nurse 
Diet of a nursing mother or wet nurse 

Drugs in human milk 
Food of infants 

Size of the infant stomach 

Overfeeding 

Methods of feeding 

Feeding by the mother or wet nurse 

Feeding by the bottle 

Mixed feeding 
Weaning 
Artificial infant foods 

Infant stools 

Nursing bottles . 

Care of infant's mouth 

Weighing of infants 

Premature infants 
Food for young children 

Rules for feeding young children 

Dietaries for young children 

Teething and food 

Sleep and food . 
Diet for school children 

Hours for meals 
Hospital dietaries . 

New York Hospital . 

Presbyterian Hospital 

Bellevue, Gouverneur, Fordham. and 

Roosevelt Hospital 

Johns Hopkins Hospital 

Liverpool Infirmary . 

Cook County Hospital 

New York Infirmary 

New York State Hospital 



Harl 



em Hospitals 



CONTENTS 



XX111 



PAGE 

Utica State Hospital for Insane 791 

Dietaries of army hospitals ......... 793 

United States ........... 795 

British ............ 797 

Prussian, French 798 



APPENDIX 



Receipts for invalid food and beverages suitable for fevers and conva 

lescence from acute illness 
Beverages 

Demulcent and nutritive 

Diuretic and refrigerant 
Fluid beef preparations 

Broths and soups 
Solid meat preparations 
Milk preparations 
Egg preparations 
Farinaceous foods 
Gelatin preparations 



799 
799 
799 
800 
801 
803 
804 
806 
807 
809 
8i3 



LIST OF ILLUSTRATIONS 



Plate I. Milk laboratory 

II. Animal fats (butter and butterine) 
III. Starch granules (wheat, barley, rye, oats, corn, and 
rice) . . 

" IV. Maize starch and wheat starch . 
Section through wheat kernel 
Microscopic characters of wheat . 

V. Rice starch 

Starch granules (marunta, potato, ginger, sago 
peas, and beans) ..... 

VII. Bean starch and pea starch . 

Potato starch ...... 

IX. Animal fats (beef fat and oleomargarine) 
Comparison of daily dietaries 
Diet sheet ....... 



VI. 



VIII. 



Facing 88 

Facing 96 

Facing 133 

Facing 136 

. 136 

. 136 

Facing 155 

Facing 158 

Facing 162 

Facing 165 

Facing 192 

. . 718 

. 784 



PRACTICAL DIETETICS 



PART I 
FOODS AND FOOD PREPARATIONS 



ELEMENTARY COMPOSITION OF FOODS 

Of the eighty-two chemical elements, thirteen enter uniformly 
into the composition of the body and ten more are occasionally 
found. Of all these, several exist in very small proportion and 
their uses are unknown, several are found more abundantly but 
are not indispensable to life, and certain elements — namely, carbon, 
hydrogen, oxygen, and nitrogen — are necessary ingredients of the 
tissues of the body. These elements form compounds which, as 
they occur in the structure of the various tissues, have the following 
characteristics : 

First, although the elements are but few in number, their molecu- 
lar arrangement is very complex. 

Second, their compounds are comparatively unstable and are 
readily converted in the body or by chemical analysis into other 
forms. 

All food is composed of combinations of these simpler chemi- 
cal elements which, for the most part, must be subjected to altera- 
tion in the body itself to prepare it for assimilation by the tis- 
sues. The nutrition of the body, therefore, involves four distinct 
processes, viz. : 

i. The secretion of digestive fluids and their action upon food in 
the alimentary canal. 

2. The absorption of the ingredients of the food when digested 
into the blood vessels and lymphatic vessels. 

3. The assimilation of the absorbed nutritious products by the 
tissues. 

4. The elimination of the waste material. 

The following analysis exhibits the relative proportion of the 
elements of which the human body is composed : 



2 FOODS AND FOOD PREPARATIONS 

Approximate Chemical Analysis of a Man (Moss) 
(Height, 5 feet 8 inches ; weight, 148 pounds.) 

Oxygen 92.4 pounds. 

Hydrogen 14.6 

Carbon 31-6 

Nitrogen 4-° 

Phosphorus 1.4 

Calcium 2.8 " 

Sulphur 0.24 " 

Chlorine 0.12 " 

Sodium 0.12 " 

Iron 0.02 " 

Potassium o. 34 " 

Magnesium 0.04 

Silica ? 

Fluorine 0.02 " 

Total 148.00 pounds. 

All these elements are necessarily derived from food and water 
plus the oxygen of the air which is breathed. 

The three predominating elements — oxygen, hydrogen, and car- 
bon — are the great force producers of the body, although they 
are tissue formers as well, and to them must be added nitrogen, 
as serving in this double capacity, although its relation to tissue 
formation and renewal is greater than its capacity for supplying 
energy. 

The common elements which enter into tissue formation chiefly 
and which bear no direct relation to the main sources of the force 
production in the body are chlorine, sulphur, phosphorus, iron, 
sodium, potassium, calcium, and magnesium in different combina- 
tions. Bone tissue, for example, contains about 50 per cent of 
lime phosphate. If this substance is deficient in the food of the 
young growing infant, the bones are poorly developed and so soft 
that they yield to the strain of the weight of the body and become 
bent and out of shape. This constitutes one of the principal symp- 
toms of rickets. 

Lack of iron salts in the food impoverishes the colouring matter 
of the red blood-corpuscles on which they depend for their power of 
carrying oxygen to the tissues, and anaemia and other disorders of 
deficient oxidation result. 

The lack of sufficient potash salts, especially potassium carbonate 
and chloride, is a factor in producing scurvy, and the condition is 
intensified by the use of common salt. A diet of salt meat and 
farinaceous foods with absence of potatoes and fresh fruit and vege- 
tables may cause it. 

The lack of sodium chloride interferes with many of the functions 
of the body immediately concerned with nutrition, such as absorp- 



ELEMENTARY COMPOSITION OF FOODS 3 

tion (osmosis), secretion, etc., and alters the density and reactions of 
the different body fluids. 

These few illustrations suggest the diversity of roles exhibited by 
the elements and the need for a correctly balanced diet. 

In order to determine what such a diet should consist of it is ne- 
cessary to study the value of the principal classes of foods in force 
production and in nutrient power or tissue building, but before pro- 
ceeding further with this discussion it will be advisable to adopt a sim- 
ple comprehensive classification of the foods in general use by man. 

The following table of analyses made by Dujardin-Beaumetz is 
quoted by Yeo to show the proportion of nitrogen present in differ- 
ent foods, and also the combustible carbon and hydrogen. 

" The hydrogen existing in the compound in excess of what is re- 
quired to form water with the oxygen present is calculated as carbon. 
It is only necessary to multiply the nitrogen by 6.5 to obtain the 
amount of dry proteids in 100 grammes of the fresh food substance : " 



Beef (uncooked) 

Roast beef 

Calf's liver 

Foie-gras. 

Sheep's kidneys 

Skate 

Cod, salted 

Herring, salted 

Herring, fresh 

Whiting 

Mackerel 

Sole 

Salmon 

Carp 

Oysters 

Lobster (uncooked) 

Eggs 

Milk (cow's) 

Cheese (Brie) 

Cheese (Gruyere) 

Cheese (Roquefort) 

Chocolate 

Wheat (hard southern, variable average). . 
Wheat (soft southern, variable average). . . 

Flour, white (Paris) 

Rye flour 

Winter barley 

Maize 

Buckwheat 

Rice 

Oatmeal 

Bread, white (Paris, thirty per cent water) 
Bread, brown (soldiers' rations formerly). 
Bread, brown (soldiers' rations at present) 

Bread from flour of hard wheat 

Potatoes 

Beans 





C + H. 


Nitrogen. 


Combustibles cal- 




culated as carbon. 


3.OO 


II.OO 


3-53 


17.76 


3-Og 


15.68 


2.12 


65.58 


2.66 


12.13 


3.83 


12.25 


5-02 


16.OO 


3- II 


23.OO 


I.83 


2I.OO 


2.41 


9.OO 


3-74 


I9.26 


I. 91 


12.25 


2.09 


16.OO 


3-49 


I2.IO 


2.13 


7- -18 


2-93 


IO.96 


I.9O 


I3-50 


O.66 


8.00 


2-93 


35- 00 


5.00 


38.00 


4.21 


44.44 


1.52 


58.00 


3.00 


41.00 


1. 81 


39.00 


1.64 


38.50 


1-75 


41.00 


1.90 


40.00 


1.70 


44.00 


2.20 


42.50 


1.80 


41.00 


i-95 


44.00 


1.08 


29.50 


1.07 


28.00 


1.20 


30.00 


2.20 


31.00 


o.33 


11.00 


4-50 


42.00 



FOODS AND FOOD PREPARATIONS 



Haricots (dry) 

Lentils (dry) 

Peas (dry) 

Carrots 

Mushrooms 

Figs (fresh) 

Figs (dry) 

Plums 

Coffee (infusion of ioo grammes). 
Tea (infusion of ioo grammes). . . 

Bacon 

Butter (fresh) 

Olive oil 

Beer, strong 

Wine 





C + H. 


Nitrogen. 


Combustibles cal- 




culated as carbon. 


3-92 


43.OO 


3-87 


43.OO 


3-66 


44.OO 


0.31 


5-50 


0.60 


4.52 


0.41 


I5-50 


0.92 


34.OO 


o.75 


28.00 


1. 10 


9.OO 


1. 00 


IO.50 


1.29 


71.14 


0.64 


83.00 


Trace 


98.OO 


0.05 


4-50 


0.15 


4.00 



To estimate the equivalent chemical elements in the different 
classes the following standards are adopted : 

1. To obtain the amount of nitrogen in proteid foods, divide the 
quantity of food by 6.50. 

2. To obtain the carbon in fat, multiply the quantity of fat by 
0.765. 

3. To obtain the carbon in carbohydrate food, multiply by 0.444. 

4. To obtain the carbon in proteid food, multiply by 0.535. 

Estimates vary somewhat as to the average quantity of the ele- 
ments carbon and nitrogen consumed per diem. In a general way it 
may be said that the consumption of carbon is 320 grammes, and 
that of nitrogen about 20 grammes. (See Quantity of Food, 
page 283.) 

FOOD CLASSIFICATION 

Foods may be classified in various ways, according to — 

1. Their physical properties. 

2. Their source. 

3. Their composition. 

4. The role which they perform in the animal body. 

Foods are classed in accordance with their general physical 
properties : First, into solid, semisolid, and liquid foods ; secondly, 
into fibrous, gelatinous, starchy, oleaginous, crystalline, and albu- 
minous foods. 

A subdivision sometimes used is that of the " complete " foods, 
such as eggs or milk, which in a single article comprise all the 
necessary ingredients and elements to support life, and " incom- 
plete " foods, which are capable of maintaining life but a compara- 
tively short time. 

Foods may be classed as to their source primarily into animal 
and vegetable foods. 

Animal foods consist of meats, fish, shellfish, and crustaceans, 



FOOD CLASSIFICATION 5 

eggs, milk and its products, animal fats, gelatin. The vegetable 
foods are subdivided into cereals, vegetables proper, fruits, sugars, 
vegetable oils. 

The simplest chemical classification possible is that advocated by 
Baron von Liebig, who was the first to suggest a really scientific 
division of foods. He grouped all foods into two classes — 

a. Nitrogenous, b. Non-nitrogenous. 

Each of these classes contains food materials derived from both 
the animal and vegetable kingdoms, although the majority of the 
animal substances belong to the nitrogenous, and the majority of 
vegetable substances to the non-nitrogenous group. 

a. The nitrogenous group von Liebig regarded as containing 
" plastic " elements — i. e., they are essentially " tissue builders " or 
" flesh formers." 

Nitrogenous foods are sometimes called " azotised foods " or 
" albuminoids " — that is, substances resembling albumin. They con- 
sist chiefly of the four elements carbon, oxygen, hydrogen, and 
nitrogen, to which a small proportion of sulphur and phosphorus are 
usually joined. These elements for the most part are combined as 
some form of albumin. 

Nitrogenous or proteid foods are non-crystallisable, but coagula- 
ble, principally fluid or semisolid substances. They are fermenta- 
ble, and under some conditions will putrefy. 

The nitrogenous group comprises all forms of animal food, ex- 
cepting fats, glycogen, and such substances as milk, sugar, and 
honey. It includes, therefore, albumins and gelatins. Its chief rep- 
resentatives are milk, eggs, crustaceans, fish, shellfish, flesh, and 
fowl. It also contains such nitrogenous substances as exist in the 
vegetable kingdom or " vegetable albuminoids." 

b. The second or non-nitrogenous group von Liebig called 
" respiratory or calorifacient foods," because their function in the 
body is to furnish fuel or maintain animal heat. Since this original 
classification was suggested it has been established that the non- 
nitrogenous aliments supply energy as force, manifested through 
muscular action, hence they are also called " force producers," in 
distinction from the nitrogenous or proteid " tissue builders." 

This is a convenient distinction to adopt, but it must not be held 
too absolutely, for in emergencies the tissue builders are used as 
force producers and heat producers as well. 

The non-nitrogenous group contains strictly only the three ele- 
ments carbon, hydrogen, and oxygen, although various salts are 
mixed with both vegetable and animal foods. It includes vegetables, 
fruits, cereals, starches, sugars, gums, fats and oils (which latter are 
both animal and vegetable), and organic acids. Many vegetables, 
besides some fruits, contain considerable nitrogen, but the " carbo- 
hydrates " — i. e., starches and sugars — constitute their main bulk. 



6 



FOODS AND FOOD PREPARATIONS 



Many vegetables, and, in fact, all starch granules, contain proteid 
material which is chiefly used in the formation of outside coverings 
to afford protection and firmness of resistance to a softer pulp within. 
Neither is animal food strictly nitrogenous, on account of its fat 
and glycogen, nor is vegetable food strictly non-nitrogenous, owing 
to its albuminoids and other forms of proteids (such as plant albumin, 
found in the legumes, etc.), yet this classification is a very con- 
venient and simple one which has met with general acceptance. It 
will be used in this book whenever a further degree of subdivision 
is not needed, but always with the understanding that it has only a 
general and not too literal application, and, unless otherwise dis- 
tinctly specified, " nitrogenous food " will be understood to include 
animal food, and " non-nitrogenous food " to include vegetable food 
of all kinds, and vice versa. 



Table of Composition of Some Common Foods 
(Hofmann.) 





Nitrogenous 
constituents. 


Fat. 


Carbo- 
hydrates. 


Salts. 


Total. 


Fat beef 


51-4 
89.4 

27-3 
16.6 

7-7 


45-6 
5-5 
0.8 
0.9 
0.4 


08^9 
81.9 
91.2 


3-o 
5-i 

3.0 

0.6 

0.7 


IOO 


Lean beef 


IOO 


Pea flour 


IOO 


Wheat 


IOO 


Rice 


IOO 







Table of Composition of Common Foods 
(Abridged from Parkes.) 



Articles. 



Beefsteak 

Fat pork 

Smoked ham 

Whitefish 

Poultry 

White wheat in bread 

Biscuit 

Oatmeal 

Maize 

Macaroni 

Arrowroot 

Peas (dry) 

Potatoes 

Carrots 

Cabbages 

Butter 

Egg (1-10 for shell) 

Cheese 

Milk (specific gravity, 1032) 

Cream 

Skimmed milk 

Sugar 



Water. 


Proteids. 


Fats. 


Carbo- 
hydrates. 


Salts. 


74-4 


20.5 


3-5 




1.6 


39-0 


9.8 


48.9 




2-3 


27.8 


24.O 


36.5 




10. 1 


78.O 


18. 1 


2.9 




1.0 


74.O 


2I.O 


3-8 




1.2 


40.O 


8.0 


1-5 


49.2 


i-3 


8.0 


15.6 


1-3 


73-4 


1.7 


15.O 


12.6 


5.6 


63.O 


3-0 


13-5 


10. 


6.7 


64-5 


i-4 


I3-I 


9.0 


0.3 


76.8 


0.8 


15-4 


0.8 




83-3 


0.27 


15-0 


22.0 


2.0 


53-o 


2.4 


74-0 


2.0 


0. 16 


21.0 


1.0 


85.0 


1.6 


O.25 


8-4 


1.0 


91.0 


1.8 


5-0 


5-8 


0.7 


6.0 


0.3 


9I.0 




2-7 


73-5 


13-5 


11. 6 


.... 


1.0 


36.8 


33-5 


24-3 




5-4 


86.8 


4.0 


3-7 


4.8 


0.7 


66.0 


2.7 


26.7 


2.8 


1.8 


88.0 


4.0 


1.8 


5-4 


0.8 


3-o 






96.5 


0.5 



FORCE PRODUCTION. ENERGY FROM FOOD J 

The foregoing analyses by Hofmann and Parkes of several com- 
mon foods illustrate the mixed character of animal and vegetable 
foods and the difficulties of a purely chemical basis of classification. 

For the purpose of the present work, it is convenient to sub- 
divide foods by the following classification: I. Water; II. Salts; 
III. Proteids (chiefly albumins and the allied gelatin) ; IV. Starches ; 
V. Sugars ; VI. Fats and oils. 

Protein is a comprehensive term used in food calculations to 
signify all nitrogenous food substances, except the nitrogenous fats. 
Proteids are nitrogenous substances of definite composition forming 
a portion of the protein class. 

Some writers class oxygen in a separate division among foods. 
This seems unnecessary, unless a separate division is made for 
hydrogen, and in fact for each element. The primary object of food 
classification is to obtain a practical working basis of subdivision, 
and the less complex this is made, the better. Further details of 
grouping belong to the refinements of physiological or organic 
chemistry, and are out of place in the present work. 

FORCE PRODUCTION. ENERGY FROM FOOD 

The two ultimate uses of all food are to supply the body with 
materials for growth or renewal, and with energy or the capacity for 
doing work. The energy received in a latent form, stored in the 
various chemical combinations of foods, is liberated as kinetic or 
active energy in two chief forms : first, as heat ; second, as motion. 
Force is the manifestation of energy. The force developed by a 
healthy adult man at ordinary labour averages 3,400 foot tons per 
diem, a foot ton being the amount of force required to raise a weight 
of one ton through the height of one foot. Of this, less than one 
fifth is expended in motion, and more than four fifths, or 2,840 foot 
tons, in heat, which maintains the body temperature at its normal 
average. A man weighing one hundred and fifty pounds — or nearly 
one thirteenth of a ton — obviously expends considerable energy in 
merely moving his own body about from place to place, aside from 
carrying any additional burden. 

The original force developed in the various functions of animal 
life which result in heat production and motion is in part obtained 
from the radiant heat of the sun stored by plants in the latent form 
of certain chemical compounds — chiefly starches and sugars — which, 
on being consumed as food by animals, furnish energy. 

A useful comparison may be made between the processes of nu- 
trition and development of energy from food in the human body 
and the energy derived from a steam engine and boiler. In both 
cases the main source of energy is oxidation, and principally of car- 
bon. In both cases the latent energy of the carbon liberated by 



8 FOODS AND FOOD PREPARATIONS 

oxidation processes is converted into heat and motion, forms of 
energy which bear a definite relation to one another. If a large 
part of the original latent energy is converted into heat, less will 
yield motion, and conversely. The proportion of these two forces 
to each other is in the case of the most perfectly constructed en- 
gine about one of motion to eight of heat; whereas in the human 
body it was calculated by Helmholtz that the motion obtainable 
from a given amount of food may stand in relation to the heat in 
the proportion of one to five. Hence, as regards the production of 
work through motion, the human body is a more perfectly con- 
structed machine than the engine. Furthermore, after combustion 
of the carbon by the fires of the boiler a certain amount of waste 
matter or ash is produced. If this is allowed to accumulate, it 
obstructs the draught and interferes with active oxidation. In the 
human body, in like manner, the fuel or food consumed produces 
ashes, such as urea and other forms of waste material, which, if not 
removed, accumulate in the system and embarrass or retard the 
normal oxidation processes. The body possesses the additional 
power of modifying and distributing the fuel food which it receives 
so as to develop its energy to the best advantage in different organs. 

R. C. Carpenter, in 1898, made an exhaustive study of the energy 
developed by a bicycle-rider named Miller. He found that the 
energy developed by this man equalled 45 per cent of the total heat 
of combustion calculated for his food. Professor Carpenter says : 
" The best record of any heat engine is probably that of the Deisal 
motor," which develops 33.7 per cent of the heat energy of its fuel, 
and " the best record of a steam engine is that of the Nordberg 
pumping engine at Pittsburg," which develops 2.2.7 P er cent °f 
energy. 

" With the exception of the Deisal motor the best record of 
any oil engine per delivered horse power is about 16.5 per cent effi- 
ciency. From this comparison it would seem that the human 
machine is decidedly superior to any heat engine which has been 
developed in form so as to be of any value for practical use." 

Whether elementary substances are burned outside of the body 
or oxidised within the body, the resulting products are the same. 
There can be no loss of matter, and there can be no loss of energy. 
The matter is simply changed in form by molecular rearrangement, 
the energy is converted from one type into another. The following 
simple experiment will illustrate this point : In a large covered glass 
jar place an ounce of alcohol in a small metal vessel. Also place in 
the jar a little lime water in a tumbler, and a thermometer. On 
igniting the alcohol and allowing it to burn away completely, a film 
of aqueous vapour will accumulate on the surface of the jar, and a 
film of calcium carbonate will form on the surface of the lime water 
produced by the union of carbonic-acid gas with the lime water. 



FORCE PRODUCTION. ENERGY FROM FOOD 9 

The thermometer will indicate a rise in temperature of the air in the 
jar. An ounce of alcohol consumed as food will be similarly con- 
verted into carbonic-acid gas and water, and in this process the body 
heat will be increased. No substance is a good food unless it fulfils 
two conditions — viz., easy assimilation and complete combustion. 
The proportion of any given food actually assimilated (i. e., not 
rejected in the feces) is called its " coefficient of digestibility." 

Metabolism within the body is not alone controlled by muscular 
work, but by the nervous energy expended in its performance. For 
example, a day labourer, like an iron founder, may be stronger and 
do much more mechanical work than an oarsman or foot-ball player 
in time of contest, yet he expends very little nervous energy in his 
routine daily work, and requires less protein in his diet than the 
athlete. In other words, severe muscular work performed for a 
brief time under conditions of great mental excitement and nervous 
tension demands an excess of protein, whereas continued muscular 
effort without great fatigue or mental strain is maintained upon a 
liberal allowance of food, which may be varied in composition if it 
be easily digestible. 

The relative importance of the different food fuels should be 
considered. This is well summarised by Charles E. Woodruff : 

" For instance, cut off the supply of oxygen, and death ensues in 
from one to ten minutes. If water is withheld, preventing the trans- 
portation of the fuel and oxygen to various parts of the body, death 
follows in about two to seven days or more, according to climate, 
exposure, and exercise. If the fuel itself is taken away, death follows 
in from seven to forty days or more, according to the amount of 
exposure that would abstract heat and the amount of work that 
would use up the energy already stored up in the body. If materials 
for the repair of tissues be excluded, death follows in a variable time, 
dependent upon the importance of the tissue that is being starved — 
a time varying from a week if all nitrogen is excluded, to several 
months if the vegetable acids are excluded, or even to several years " 
— if certain more obscure substances are withheld. 

It still remains extremely difficult in the case of all foods to 
trace their final uses in the body and determine with any approach 
to accuracy what proportions of each furnish respectively energy, 
repair of tissue, and heat, for there are no more complex chemical 
processes known than those of tissue metabolism. In other words, 
it is necessary to determine whether the actual physiological value 
of food in the body as producing energy for muscular activity and 
body heat corresponds with its calculated or calorimetric value, and 
to determine standards of " fuel value." 

In order to study the quantity of energy which may be derived 
from different varieties of food, a man or an animal may be placed 
in an apparatus known as a calorimeter. There are numerous types 
3 



10 FOODS AND FOOD PREPARATIONS 

of such apparatus, and Professor Atwater collected, in 1897, data 
of 3,661 calorimeter experiments, 2,299 of which have been made 
by various observers upon man. In the great majority of these 
experiments the nitrogen balance was determined, and the carbon 
balance was computed by deduction, but in a few the latter was de- 
termined directly. The most elaborate and ingenious apparatus of 
this sort is the " respiration calorimeter " constructed at Wesleyan 
University by Profs. W. O. Atwater and E. B. Rosa. It con- 
sists of a chamber seven feet long, six feet four inches high, and 
four feet wide, in which a man may remain day and night, being sup- 
plied with fresh air and food. The chamber is practically a many- 
walled, air-tight box having air spaces between the walls which 
are so constructed as to maintain a uniform temperature within and 
prevent all external temperature changes from affecting the interior. 
There are two inner metal walls composed respectively of copper 
and zinc, and three outer wooden walls reinforced by thick builders' 
paper. Between these five walls, which completely surround the 
box, over top and bottom as well as sides, are four air spaces several 
inches in thickness, two containing dead air and two circulating air, 
kept in motion by electric fans and warmed or cooled according to 
need, so as to maintain a constant temperature within. A glass* 
window constructed with successive layers like the walls serves to 
admit the man under observation, after which it is hermetically 
soldered. A small air lock is used to admit food and to pass out 
excrement for analysis. The chamber contains a folding bed, table, 
and chair, a pair of scales, and a stationary bicycle which operates 
a small dynamo and electric light. The heat from the light is meas- 
ured, together with that dissipated from the man's body within the 
chamber, and this gives a measure of muscular work converted into 
the energy of heat. The heat is conveyed away from the chamber 
by means of a current of cold water passing through copper pipes, 
and is measured by electric thermometers. Circulating air is sup- 
plied to the interior of the chamber, and samples are withdrawn for 
analysis as it enters and leaves the chamber. In this manner is 
measured the quantity of C0 2 and water eliminated through the 
lungs and skin. The volume and temperature of the air is carefully 
regulated. The subject of experimentation is put upon a measured 
diet for four days before entering the calorimeter in order to estab- 
lish nitrogenous equilibrium and record observations upon the food 
excrement, amount of work performed, etc. He then enters the 
calorimeter, where he remains four days and five nights. In the " test 
experiments " the subject makes as little muscular exertion as pos- 
sible, but in the " work experiments " he operates the stationary 
bicycle for eight hours a day. The delicacy of the apparatus is 
shown by the fact that in the thermo-electric measurement system 
304 pairs of metallic junctions are distributed throughout the inner 



FORCE PRODUCTION. ENERGY FROM FOOD 



I I 



wall air space, and the heat generated by such slight movements as 
turning in bed or rising from a chair at once produces a deflection of 
the thermal galvanometer. The main value of the experiments 
thus far conducted in this calorimeter consists in the actual demon- 
stration that the law of the conservation of energy operates within 
the body in precisely the same manner that it does outside. In 
man it was found that the measured energy of the food consumed 
by the subject within the calorimeter was within 99 per cent of the 
calculated or theoretical energy. A margin of 1 per cent of error 
is certainly very small in view of the difficulties of such complicated 
experiments. It is possible that some of the energy was perma- 
nently stored within the body, and another physiological source of 
slight error lies in possible differences in temperature of the whole 
body between entering and leaving the calorimeter. The other 
important use of the respiration calorimeter is to determine the fuel 
value of different foods, alcohol, etc., in furnishing heat and motion 
for the body. The complete calorimeter experiment comprises : 
(1) weighing and analysis of food, feces, and urine ; (2) determination 
of the C0 2 and water eliminated by the patient ; (3) estimation of 
the energy produced by the body in the form of heat, both when at 
rest and in motion, the motion being converted into heat by means 
of the bicycle and dynamo above described. The results obtained 
by Professor Atwater in two of his calorimeter experiments are tabu- 
lated by him as follows : 

Comparison of Daily Income and Outgo of Protein and of Energy in the 
Rest and Work Experiments (Nos. p and 6) 





PROTEIN. 


ENERGY. 


Experiment. 


Of food. 


Actually 
oxidised. 


Of food. 


Of 

material 
actually 
oxidised. 


Measured. 


Difference 
in per cent 
of heat of 
material 
actually 
oxidised. 


Rest (No. 9) 


Grammes. 
H9-4 
H9-4 


Grammes. 

115. 

103. 1 


Calories. 
2,717 
3,678 


Calories. 
2,275 
3,830 


Calories. 
2,3lO 
3,726 


Per cent. 
+ 1.5 
- 2.7 


Work (No. 6) 



Average Daily Income and Outgo of Nitrogen and Carbon in the Rest and 
Work Experiments (Nos. g and 6), with the Estimated Gain or Loss 
of Protein and of Fat 





NITROGEN. 


CARBON. 


CALCULATED 
GAIN OR LOSS. 


Experiment. 


In 

food. 


In 

feces. 


In 
urine. 


Gain 
(+)or 

loss 


In 
food. 


In 
feces. 


In 
urine. 


In re- 
spira- 
tory 
prod- 
ucts. 


Gain 

( + ) or 
loss 


Of pro- 
tein. 


Of fat. 


Rest (No. 9).. 
Work (No. 6). 


Gms. 
I 9 . 1 
19. 1 


Gms. 
1.2 

1-5 


Gms. 
18.4 
16.5 


Gms. 
-O.6 

+ I.I 


Gms. 
261.5 
336.7 


Gms. 
13.3 
12.4 


Gms. 
12.6 
12.5 


Gms. 
223.6 
345 2 


Gms. 
+ I2.0 
-33-3 


Gms. 
-3.6 
+ 6.9 


Gms. 

+ I8.2 
-48.3 



12 FOODS AND FOOD PREPARATIONS 

An ingenious device was used to differentiate the feces belonging 
to the period of experimentation before entering the calorimeter 
from those following ingestion of food within the apparatus. To 
do this, just before entering the calorimeter the man is required to 
take a few grains of lampblack with his food. This harmless sub- 
stance colours the stool and marks the dividing line. 

The unit of measurement used in calorimeter experiments is the 
calorie, which is the amount of heat required to raise I kilogramme 
of water from o° to i° C. ; this equals 3,100 foot pounds, or, approxi- 
mately, it is the heat required to raise one pound of water 4 Fahren- 
heit. Fuel value is a term denoting the total calories derivable from 
a pound of any given food substance if it be completely combusted 
within the body. The fuel values are calculated for a given food by 
the factors of Rubner as follows: 4.1 calories per gramme of either 
protein or carbohydrate, and 9.3 calories per gramme of fat. This 
corresponds with 18.6 calories of energy for each hundredth of a 
pound of protein or carbohydrate and 42.2 calories for the same 
quantity of fat in any food (W. O. Atwater). Or, as stated by C. F. 
Langworthy, the fuel value of the three chief classes of nutrients is 
as follows : 

One pound of protein yields 1,860 calories. 

" " " fats " 4,220 " 

" " " carbohydrates i,86o " 

" In other words, when we compare the nutrients in respect to 
their fuel values, their capacities for yielding heat and mechanical 
power, a pound of protein of lean meat or albumin of egg is just 
about equivalent to a pound of sugar or starch, and a little over two 
pounds of either would be required to equal a pound of the fat of 
meat or butter or the body fat." 

The work of the average man is calculated to be about 2,000,000 
foot pounds per diem (R. H. Thurston). This may exceptionally 
be increased to 3,000,000 foot pounds. According to the study of 
R. C. Carpenter of a phenomenal athlete named Miller, the latter 
developed work amounting to over 15,000,000 foot pounds (7,500 
foot tons) on the first day of a six-days' bicycle contest, and 5,500,000 
foot pounds (2,750 foot tons) on the last day. 

Elaborate investigations have been made with all the principal 
classes of foods in order to estimate their nutrient, their heat-pro- 
ducing, and their force-producing value, and many statistical tables 
have been compiled. It should be remembered that a(l this work 
is merely approximate, and that the liability to error in 1 the various 
factors is considerable, but in a general way the results jare instruc- 
tive, and they are certainly interesting and not altogether without 
practical application. " The fuel value of a pound of protein as it is 
ordinarily burned in the body is very nearly the same as that of a 



FORCE PRODUCTION. ENERGY FROM FOOD 1 3 

pound of carbohydrates, but fats have a fuel value of two and one 
quarter times that of protein and carbohydrates, or 4,220 calories 
per pound " (A. C. True). A day labourer requires 0.28 pound of 
protein per diem plus enough fat and carbohydrate to yield a total 
fuel value of 3.500 calories. A professional man requires 0.22 to 
0.25 pound of protein to yield 2,700 to 3,000 calories of energy, but 
more than that is often consumed. Study at the Storrs experiment 
station in Connecticut (1896) of nine families of professional men 
showed an actual consumption of 107 grammes of protein, and a diet 
fuel value of 3,430 calories.^ The standard for a man at light mus- 
cular labour demands 112 grammes of protein and a fuel value of 
3,000 calories. 

The mere calculation of the nitrogen and carbon in a food does 
not at all show its force value in the body, unless it can at the same 
time be demonstrated that it is assimilable. Many substances appear 
to contain abundant food energy which in reality are not economical 
foods at all from the point of view of supplying all the needs of the 
body ; thus beef fat is wholesome, but it contains no nitrogen for 
tissue building, and peas contain a large proportion of flesh formers 
as compared with heat givers. Wood pulp can be made to furnish 
cellulose and yield much energy, but it is worse than useless in the 
stomach of man, although some of the lower animals, like rodents, 
can digest it and make it available for nutrition. Sugar can be 
made from old rags in the laboratory, yet no stomach can deal with 
such material. 

Tables are now available for the calculation of the force value 
of rations for large bodies of men under different conditions, as, for 
example, soldiers in barracks or on the march, which are based upon 
the principle of careful comparisons between the income and output 
of energy of the body. That is to say, a study of the force-producing 
value of different classes of foods, as obtained by chemical research 
in the laboratory, is carefully compared with the amount of waste 
matter which is eliminated by the system while a man is being fed 
upon a measured quantity of food and kept under uniform conditions 
as regards the amount of work performed. In this manner a check 
is established upon the theoretical calculations of food values as com- 
pared with their practical uses in maintaining the equilibrium of the 
body. Obviously these experiments require great care and system, 
and if they are to be made of intrinsic value they can only be con- 
ducted by expert physiological chemists upon persons who are wil- 
ling to subject themselves from periods varying from several days 
to several weeks to conditions involving monotony of diet and 
existence. For this reason the number of actual experiments of 
this kind which have been made is comparatively small, and the 
conclusions drawn from them must be accepted with considerable 
allowance for possible error. A diet system to which a man may be 



H 



FOODS AND FOOD PREPARATIONS 



willing to submit for a few weeks is by no means always that which 
will prove best for him through a longer period, and a too rigid ap- 
plication of the rules established for the computation of the force 
value of foods yields much less practical results than the experience 
derived by those who actually control the commissary department 
with due regard to proper economy and variation in food, but entirely 
without resort to calculations of grammes of carbon, nitrogen, etc. 

A criticism reached me from the inmates of a large girls' college, 
where the diet was for some time experimentally regulated by an 
expert in such matters, that " if one half the time were bestowed 
upon properly serving and selecting the food that is given to com- 
putation of its force-producing value, the girls would have very 
much better appetites and digestion/' On the other hand, it is easy 
to err if the dictates of hunger and capriciousness of appetite are 
allowed to wholly control diet. In the lower animals the instincts 
which these factors develop are very much safer guides than in the 
case of man. 

Nevertheless, the knowledge derived from experiments of the 
kind under discussion is certainly useful and instructive, when allow- 
ance is made for its relative value by taking into consideration the 
wide range of circumstances that will modify its application which 
occur in the organisation of different persons, in their varying 
capacity for work, and in the condition of their external surround- 
ings. With this word of explanation the following tables from dif- 
ferent authors are reproduced. It will be observed that there are 
some few discrepancies among them, but the cause has been ex- 
plained above. 

The following table of analyses, given by Major Charles E. 
Woodruff, M. D., Surgeon, United States Army, differs in some 
details from the preceding table by Parkes (p. 6), and adds several 
foods with their calories : 

Percentage Composition of Edible Portions of Garrison Ration 



fat. 



Bacon, 

Beans 

Pork, salt and fat. . 

Sugar, ground 

Sugar, brown issue. 

Flour 

Beef. 

Potatoes 

Onions 

Oatmeal , 

Cornmeal , 

Canned apples 

Dried apples 



Water. 



Tapioca or cornstarch, 



20. 
12.6 

12. 1 
2.0 
3.0 

12.5 
55-o 
78.9 
87.6 

7.6 
15.0 
83.2 
25.0 

2.0 



Protein. 



8.00 

23.IO 

O.90 



II.OO 

17.IO 

2.IO 

1-4 



[5.IO 
9.20 
0.20 
0.90 



Fats. 



09-5 
2.0 

82.8 



1.0 

27.O 

O.I 

0.3 

7-i 

3.8 
0.4 
1.8 



Carbo- 
hydrates. 



Salts. 



5 
1 
2 

2 

5 
5 
9 
.0 
.6 
.0 
1.4 

0.3 
1.4 
0.2 



Energy, 
calories 
per lb. 



3,o8o 
1,615 
3,5IO 
1,820 

i,795 
1,644 
1,460 

375 
225 
1,850 
1,645 
315 
1,418 
1,820 



FORCE PRODUCTION. ENERGY FROM FOOD 



15 



Butter 

Sirup 

Lard 

Rice 

Canned corn 

Canned tomatoes 

Macaroni and vermicelli . 

Milk, fresh 

Milk, condensed 

Peas 

Raisins 

Cheese 

Prunes 

Cabbage 

Ham 

Apricots, canned 

Barley 

Chocolate 

Sausage 

Oysters 

Salmon, canned 

Crabs 

Crackers 



Water. 



10.5 
43.7 

12.0 

12.4 
81.3 

96.0 

13. 1 
14. 

25 

12, 

40 

35. 

30.0 

92.0 

41.5 
50.0 

12.0 
41.2 
87.1 
63.6 



Protein. 



I. OO 

O.60 

7-4 
2.80 
O.80 
9.OO 
O.843 
17.OO 
26.70 
O.4O 

33 -oo 
2.50 
2.10 

16.7 
2.00 

13.00 

20.00 

13.80 
6.00 

21.60 

15.0 

10.3 



Fats. 



Carbo- 
hydrates. 



85.O 

83*4 
0.4 
1.1 
0.4 
0.3 



802 
o 



0.6 

39-i 

2-7 
50.0 
42.8 

1.2 

13-4 
1.0 

9.4 



0.5 
55-0 

79-4 
13.2 

2-5 
76.8 

1.069 
44.00 
56.40 
24.00 

5 00 
12.0 

5-5 

30.0 
76.0 
10. o 

3-7 



Salts. 



70.5 



3-o 
2-3 
4.0 
0.4 
0.6 

0.3 
0.8 
0.164 
3-o 
2.9 
0.6 
5-o 
0.6 
1 

7 
.6 
.0 
.0 

2 
.0 

4 



Energy, 
calories 
per lb. 



3.615 
1,023 
3,570 
1,630 

345 

80 

1,406 

418 
i,595 
1,565 

440 
1,600 

140 

155 
1,960 

460 
1,800 
2,650 
2,065 

230 

965 
526 

1,900 



Standards for Daily Dietaries 

(Compiled by Atwater.) 

Weights of nutrients and calories of energy (heat units) in nutrients required in food 

per day. 



Children up to a year and a half. . 

Children of two to six years 

Children of six to fifteen years .... 

Aged woman 

Aged man , 

Women at moderate work (Voit). , 
Man at moderate work (Voit). ... 

Man at hard work (Voit) 

Man with moderate exercise (Play 

fair) 

Active labour (Playfair) 

Hard labour (Playfair) , 

Women with light exercise (At 

water) , 

Man with light exercise (Atwater). 
Man at moderate work (Atwater). , 

Man at hard work (Atwater) , 

Man at moderate work (Moleschott) 
Man at moderate work (Wolff).. 





NUTRIENTS. 














Potential 


Protein. 


Fats. 


Carbo- 
hydrates. 


Total. 


energy. 


Grammes. 


Grammes. 


Grammes. 


Grms. 


Calories. 


28 


37 


75 


140 


767 


(20-36) 


(30-45) 


(60-90) 






55 


40 


200 


295 


I,4l8 


(36-70) 


(35-48) 


(100-250) 






75 


43 


325 


443 


2,041 


(70-80) 


(37-5o) 


(250-400) 






80 


5o 


260 


39° 


1,859 


100 


68 


350 


5i8 


2,477 


92 


44 


400 


536 


2426 


118 


56 


500 


674 


3,o55 


145 


100 


450 


695 


3,370 


119 


5i 


53i 


701 


3,139 


156 


7i 


568 


795 


3,629 


185 


7i 


568 


824 


3.74S 


80 


80 


300 


460 


2,300 


100 


100 


360 


460 


2,820 


125 


125 


450 


700 


3,520 


150 


150 


500 


800 


4,060 


130 


40 


550 


720 


3,160 


120 


35 


540 


695 


3,032 



i6 



FOODS AND FOOD PREPARATIONS 



Church furnishes the following table showing the number of tons 
which it is calculated could be raised through the height of one foot 
bv the complete combustion of a single pound of each kind of food. 
In the body only about a fifth of this energy would develop work, the 
rest going into heat production : 



i pound beef fat 


raises 


5,649 tons 


1 foot high. 


" oatmeal 


" 


2,439 " 


" " 


" gelatin 


" 


2,270 " 


" " 


" lean beef 


" 


885 " 


" 


" potatoes 


" 


618 " 


" " 


" milk 


" 


390 " 


" " 


" ground rice 


" 


2,330 " 


11 ti 



Landois and Stirling give the following table, which differs some- 
what from other estimates in the relative proportion of fats and 
starches. An adult doing a moderate amount of work takes in as 
food per diem — 





C. 


H. 


N. 


O. 


120 grammes albumin, containing. . . . 

90 " fats, containing 

330 " starches, containing. . . . 


64.18 

70.20 

146.82 

281.20 


8.60 
IO.26 
20.33 


18.88 


28.34 

9-54 
162.85 




39-19 


18.88 


200.73 



Add 744.11 grammes O. from the air by respiration. 
" 2,818.00 " H 2 0. 
" 32.00 " inorganic compounds (salts). 

The whole is equal to three kilogrammes and a half (seven 
pounds), i. e., about a twentieth of the body weight, so that about 
6 per cent of the water, about 6 per cent of the fat, about 1 per cent 
of the albumin, and about 0.4 per cent of the salts of the body are daily 
transformed within the organism. 

An adult doing a moderate amount of work eliminates in 
grammes : 



By respiration. 
By perspiration 

By urine 

By feces 



Water. 


C. 


H. 

3o 
3-o 


N. 


330 

660 

IJOO 

128 


248. s 

2.6 

9.8 

20.0 


i 5 :s 
3.0 


2,8l8 


2S1.2 


6.3 


18.8 



651-15 

7-2 

II. I 

12.0 

681.45 



The following table is a fair average work ration in round num- 
bers, based on such data as those in the foregoing tables : 



FORCE PRODUCTION. ENERGY FROM FOOD 



Estimated Work Ration, Maximum and Minimum 



(Mrs. E. H. Richards.) 



For one day. 
125 

no 

125 

90 
45o 
420 



Proteid, grammes 

Fat, grammes 

Carbohydrates, grammes 

Calories \ 3 ' 5 °° 

I 3,ooo 

About thirty grammes of salts should be added to this (Landois). 
The bare subsistence ration is much less, as follows : 

Estimated Ration to barely Sustain Life 

(Mrs. E. H. Richards.) For one day. 

Proteid, grammes 75 

Fat, grammes 40 



Carbohydrates, grammes 325 

Calories 2,000 

Professor Egleston's standard of nutrition is high. He places the 
daily allowance of nutritive material at 700 grammes, divided as fol- 
lows : Carbohydrates, 400 grammes ; fats, 150 grammes ; proteid, 150 
grammes ; yielding in all, 3,650 calories. 

The average percentage of the different food classes needed to 
sustain a man in perfect health is thus given in the Kensington Mu- 
seum Handbook on Food : 

Percentage. 

Water 81.5 

Albuminoids or flesh formers 3.9 

Starches and sugars 10.6 

Fat 3.0 

Salt (NaCl) 0.7 

Phosphates, potash salts, etc 0.3 

An Ideal Ration with Solid Food 
(Mrs. E. H. Richards.) 





AMOUNT. 


PROTEID. 


FATS. 


CARBOHYDRATES. 




Material. 


Grms. 


Oz. 


Grms. 


Oz. 


Grms. j Oz. 


Grms. 


Oz. 


Calories. 




453-6 

226.8 

226.8 

28.3 

H3-4 

453-6 

28.3 

14.17 


16 

8 
8 
1 

4 
16 
1 
\ 


31-75 
34-02 
12.52 
6.60 
3.63 
18.14 

0. 14 
106.80 


1. 12 
I.20 
O.44 
O.23 
O.I3 
O.64 


2 . 26 . 08 


257.28 

9.60 

4.88 
90.72 
27.36 

389.84 


9.04 

0.34 

0.17 

3.20 
0.96 


1,206.82 


Meat 

Oysters 

Breakfast cocoa. 
Milk 


11-34 
2.04 

7-5o 

d. J.2 


O.4O 
O.O7 
O.26 
0. t6 


243.72 

70.OI 

135-42 

75-55 


Broth 

Sugar 

Butter 


18.I4 | O.64 
12.27 .... 


613.21 
112. 17 
II8.62 


Total 









57-97 •••• 




2,575.52 



It will be observed that the totals are somewhat less in this diet 
than those of the table at the top of this page, which was adapted for 
a working man, who is developing more calories. 



i8 



FOODS AND FOOD PREPARATIONS 



Table of E?iergy estimated in Foot Tons instead of Calories (Yeo) 
Energy developed by one ounce of the following foods when oxidised in the body. 



Food Stuff. 



Beef (best quality), uncooked 

Meat (served to soldiers), uncooked 

Beef (fattened), uncooked 

Meat, cooked 

Corned beef (Chicago) 

Salt beef 

Salt pork 

Fat pork 

Dried bacon 

Smoked ham 

Whitefish 

Poultry ■ 

Bread 

Wheat flour 

Biscuit 

Rice 

Oatmeal 

Maize 

Macaroni 

Millet 

Arrowroot 

Peas (dried) 

Potatoes 

Carrots 

Cabbage 

Butter 

Eggs 

Cheese 

Milk (cow's) new 

Cream 

Skimmed milk 

Sugar 

Pemmican 

Ale (Bass's bottled) 

Stout (Guinness) 



With usual per- 


One ounce 


centage of water. 


water-free. 


Foot tons. 


Foot tons. 


48.5 


199 


57-8 


243 


96.O 


280 


I02.6 


240 


124.O 


217 


52.0 


138 


71.6 


166 


202.0 


336 


292.3 


346 


179.6 


267 


44.3 


209 


50.7 


204 


87.5 


147 


I23.6 


146 


173-3 


189 


126.5 


141 


130.0 


154 


132.0 


160 


122.7 


146 


125.9 


149 


116. 4 


138 


118. 9 


151 


33-o 


141 


14-3 


137 


13.0 


158 


344-5 


367 


07-3 


265 


149.9 


245 


26.9 


225 


109.2 


365 


20.4 


l8l 


126.4 


128 


270.1 


293 


30.0 


260 


4i-5 


360 



FORCE-PRODUCING VALUE OF THE DIFFERENT 
CLASSES OF FOODS 

I. Water. — Estimated as a force producer within the body, water 
may be said to have comparatively little value. Much of the water 
which is either drunk or ingested in combination with foods passes 
through the body unchanged, and is eliminated from one or more of 
the excreting surfaces ; but some of it is undoubtedly altered or split 
up into elements which unite with other compounds. The nature of 
these processes is obscure, and as yet very little understood. It is 
believed also that a certain quantity of water is produced in the body 
by the union of oxygen and hydrogen which occurs incident to other 
chemical change, or by the liberation of water from more complex 
molecules. Water is entitled to rank as a food because it enters 



FORCE-PRODUCING VALUE OF FOODS 19 

into the structural composition of all the tissues of the body, and, 
in fact, constitutes rather more than two thirds (70 per cent) of 
the entire body weight. Its importance is readily appreciated after 
it has been withheld from the diet for a short time, when striking 
physical and physiological alterations in the functions of the body 
occur. 

Yeo says that, " assuming the water-free food to be 23 ounces, 
and a man's weight to be 150 pounds, each pound weight of the 
body receives in twenty-four hours 0.15 ounce, or the whole body 
receives nearly a hundredth part of its own weight. But ordinary 
solid food contains usually between 50 and 60 per cent of water; 
and if we add this to the water-free solids, the total daily amount 
of so-called dry food (exclusive of liquids) is about 48 to 60 ounces. 
But from 50 to 80 ounces of water in the liquid form is usually taken 
in addition, and this would make the total supply of water equal 
70 to 90 ounces, or half an ounce for each pound of body weight. ,, 

II. Salts. — The salts have practically no force-producing power, 
but they are concerned in tissue formation to some extent, especially 
in the bones and teeth, where the lime and magnesium compounds 
are the most stable of any in the body. Some of the compounds of 
sulphur and phosphorus which exist in meat and bran are undoubt- 
edly associated with the development of energy in the body, but the 
salts are already saturated and stable, and, although their functions 
as laboratory reagents within the body are numerous, they may be 
left out of calculations of force-producing foods. 

III. Proteids, Carbohydrates, and Fats. — It is easy to determine 
with accuracy the force value of a pound of albumin by chemical 
analysis, but it does not follow from this that the energy contained 
in it will all be developed in the body at exactly the right time or 
even within a sufficiently short period to enable the system to utilise 
it completely. The majority of physiologists are agreed that mus- 
cular energy is chiefly derived from non-nitrogenous foods. This 
statement receives further confirmation in the results of an interest- 
ing series of experiments made upon sixteen persons by Prof. Charles 
E. Waite, of the University of Tennessee (U. S. Department of 
Agriculture Bulletin No. 89, 1901). The experiments included rest 
intervals followed by work periods, usually of about four hours per 
diem. Waite found that the digestibility of the diet was uninfluenced 
by moderate work, animal protein being more completely digested 
than vegetable protein. He concludes as follows : 

" A study of the nitrogen balance shows that in the majority of 
cases if there was a gain during the rest period it was increased dur- 
ing the work period, and if there was a loss it was diminished. In 
other words, comparing the elimination of nitrogen in the urine 
during the periods of little muscular activity and normal diet with 
that during periods of increased activity and a diet furnishing energy 



20 FOODS AND FOOD PREPARATIONS 

largely in excess of the heat equivalent of the measured work per- 
formed, there seems to be a slight decrease under the latter condition. 
This is true even when we consider the possibilities of a small loss 
of nitrogen in the perspiration and a lag of considerable duration 
between the breaking down of nitrogenous material within the body 
and the excretion of nitrogen in the urine." 

W. O. Atwater and H. C. Sherman state (U. S. Department of 
Agriculture, Bulletin No. 98, 1901) that: 

" Practically all of the recent experimenting with men sustains the 
view that muscular work normally results in an increased excretion 
of nitrogen when the work is at all severe and there is not a corre- 
sponding increase in the fuel ingredients (fats or carbohydrates) of 
the diet. It also implies that the increased output of nitrogen con- 
tinues after the work stops, so that if the experiment continues but 
one day the larger part of the increase may be found on the succeed- 
ing day. 

" Well-trained professional athletes when engaged in severe mus- 
cular exertion metabolise relatively large amounts of protein, the 
body tissue being drawn upon unless the protein of the food is very 
abundant." 

The daily quantity of solid food consumed by an adult male at 
ordinary work will range between 50 and 60 ounces, and that of 
water drunk is about the same. The requirements of severe labour, 
if continued, exceed this range, so that as much as 75 ounces of solid 
food may become necessary, and this should be mainly in the form 
of albuminates and fats. Fats, compared with carbohydrates, yield 
two and one fourth parts as much energy. The standard diet for 
twenty-four hours for a healthy adult male at ordinary work should 
contain, in round numbers, 20 grammes of nitrogen (contained in 
120 grammes of proteid) and 320 grammes of carbon, a proportion 
of 1 to 16, but, because the food is best taken in the form of a mixed 
diet, the proportion may be stated as one part of nitrogenous or 
animal food to three or three and one half of non-nitrogenous or 
vegetable food. Ordinary albuminous food yields, on the average, 
about 16 per cent of nitrogen. 

Nitrogen Balance. — The nitrogen in the urine and feces may be 
regarded as an index of the proteid food assimilated, and when these 
two factors correspond, the body is said to be in " nitrogen equi- 
librium," i. e., all the nitrogen actually consumed is eliminated with- 
out storage in the body. When the body has attained its full adult 
size, it maintains this equilibrium with but very slight variation. A 
new diet containing either an excess or diminution of protein tem- 
porarily disturbs this equilibrium, but it is soon readjusted. 

For an adult male the average consumption of nitrogen being 20 
grammes per diem, the ordinary allowance for daily variation does 
not exceed 3 grammes on either side of this standard. For a man 



FORCE-PRODUCING VALUE OF FOODS 21 

of average weight — that is, 67 kilogrammes, or 160 pounds — the 
daily allowance of food ranges from 6 to 9 grains of carbon, and 0.25 
to 0.36 grain of nitrogen per kilogramme of body weight. Those 
elementary foods which approach most nearly in composition the 
economical proportion of nitrogenous to non-nitrogenous material 
are cow's milk and wheat flour. In the former this proportion is one 
to three, in the latter one to four and a half. The standard ratio 
for health of protein to the fuel ingredients — starch, sugar, and 
fat — is 1 to 5.8. This is the ratio adopted by the Experiment Sta- 
tions of the United States Department of Agriculture. In metabo- 
lism experiments a time allowance must be made for the interval 
between the ingestion of proteid food and the corresponding nitro- 
gen increase in urine and feces. This interval is known as the 
" nitrogen lag," and it occupies a number of hours, varying under 
changing conditions. - 

The question of the nutritive value of any fixed diet cannot be 
solely estimated from variations in the body weight, for the loss of 
water or of albumin may increase while fat is stored up. Neither 
can the quantity of food eaten be relied upon for this purpose, for 
from habit one man may eat more than another while doing the same 
work, and may eat more than he needs. Nor is it possible to deter- 
mine from the various excreta alone whether the body has had a 
suitable quantity of nourishment, for they are too constantly chang- 
ing, and " life will soon become extinct if the nutriment given be 
measured by the metabolism of starvation " (Bauer). 

A man in perfect health might easily lose weight upon the iden- 
tical diet w r hich would enable an emaciated and feeble invalid to gain 
flesh. In convalescence from typhoid fever, for example, one often 
sees evidence of a daily gain in w r eight while the quantity of food is 
still far below that necessary to support a healthy man in vigour. 
The needs of the organism at any particular time must, therefore, be 
taken into account as well as the strength of the digestive organs in 
prescribing the quantity of food consumed. In making calculations 
for the quantity of food required by large numbers of persons under 
any conditions, somewhat more than the averages above stated 
should be always included in order to make allowance for variations 
in absorption and assimilation of the food by different individuals. 
(See Quantity of Food Required, page 283.) 

The carbohydrates are not as available for the repair and growth 
of the tissues as the fats, but by their oxidation they save tissue 
waste, and furnish both heat and muscle force. They limit the 
formation of acetone from fat when the latter is eaten in excess 
(Schuman-Leclercq) . 

Bauer says : " The easy metabolism of the carbohydrates in the 
body must not be regarded as depending on their great affinity for 
oxygen ; its cause is to be sought far more in the properties of the 



22 FOODS AND FOOD PREPARATIONS 

animal tissues. . . . The action of the carbohydrates agrees in 
many respects with that of fat, since they are in like manner capa- 
ble of protecting from metabolism a certain amount of the circu- 
lating albumin and of assisting its transformation into organic 
albumin." 

But the destruction of carbohydrates in the body is very com- 
plete, even when eaten in excess, and herein they differ from the 
fats, " an excess of which in the food invariably produces an ac- 
cession of fat." From these and other statements made by Bauer 
he argues that probably the carbohydrates do not directly form fat in 
the body, but their well-known fattening action is, when eaten with 
albumin and fat, to spare the consumption of these latter substances, 
which are then converted into tissue fat. 

Sugar furnishes, in addition to heat, considerable muscle energy, 
and it has been lately proved by Mosso, Vaughan Harley, and others 
to have distinct power in relieving muscular fatigue. 

Vaughan Harley found that with an exclusive diet of seventeen 
and one half ounces of sugar dissolved in water he could perform 
almost as much muscular work as upon a full mixed diet. The effect 
in lessening muscle fatigue was noticeable in half an hour and reached 
a maximum in two hours. Three or four ounces of sugar taken be- 
fore the expected onset of fatigue postponed or entirely inhibited 
the sensation. Schumberg recommends that the sugar be taken with 
chocolate or in lemonade. Experiments were made by him upon 
German soldiers which covered a period of thirty-eight days. The 
men were given daily ten lumps of sugar (about one sixth pound), 
and were able to withstand hunger, thirst, and fatigue much better 
than others whose diet contained no sugar. When a muscle con- 
tracts it is not the muscle tissue itself which is consumed, but its- 
supply of glycogen. The candle wick is but very slowly burned 
so long as its supply of tallow does not fail, and so the muscle is 
spared while the carbohydrate glycogen furnishes force. When a 
muscle is much used it increases in size, and needs more nitrogen to 
build new substance. 

The food value of sugar is thus summarised by Mary Hinman 
Abel (U. S. Department of Agriculture, Farmers' Bulletin No. 93, 
1899) : 

" (1) When the organism is adapted to the digestion of starch, and 
there is sufficient time for its utilisation, sugar has no advantage 
over starch as a food for muscular work except as a preventive of 
fatigue. 

" (2) In small quantities and in not too concentrated form sugar 
will take the place, practically speaking, weight for weight, of 
starch as a food for muscular work, barring the difference in 
energy and in time required to digest them, sugar having here the 
advantage. 



STIMULATING FOODS 23 

" (3) It furnishes the needed carbohydrate material to organisms 
that have as yet little or no power to digest starch. Thus, milk 
sugar is part of the natural food of the infant. 

" (4) In times of great exertion or exhausting labour, the 
rapidity with which it is assimilated gives it certain advantages over 
starch." 

The hard-working lumbermen of Canada and Maine eat a very 
large quantity of sugar in the form of molasses. I have seen them 
add it to tea and to almost everything they cook. Sugar has also 
been found of much service upon polar expeditions. 

Albumin burned in oxygen outside of the body is almost com- 
pletely oxidised, but after oxidation in the body, about one third of 
its substance is excreted, imperfectly consumed, as urea. Pfliiger 
says : " All work of life can be performed by albumin alone, while 
no other material in the universe can do it. The integral ingredient 
of the living and working cell is the albumin, indeed often the only 
organic part of it." On the other hand, the consumption of some 
carbohydrates, such as alcohol and sugar, appears as complete within 
the body as it may be outside of it, and the amount of energy actu- 
ally developed is identical with that which may be theoretically 
calculated. 

The statement is sometimes made that the compounds of carbon 
and hydrogen are slowly oxidised, and give a more continuous yield 
of energy than nitrogenous compounds, but with less powerful indi- 
vidual discharges. In other words, they are said to be good " main- 
tamers of energy." There are, however, exceptions to this, such as 
alcohol. 

The proportion of nitrogenous or proteid compounds required is 
greatest where growth is active. Many nitrogenous substances pos- 
sess high potential and explosive energy, as illustrated by nitro- 
glycerin and fulminating powder. Proteids are always present where 
the phenomena of life are exhibited, and bear a direct relation to 
their activity. 

STIMULATING FOODS 

In the broadest sense all food is stimulating to the functional ac- 
tivities of the body ; but when the digestive and assimilative powers 
are lowered, less variety and less quantity of food can be tolerated, 
and foods that in health are never needed may become necessities ; 
such foods, for example, are cod-liver oil and the various prepara- 
tions of meat, such as albumoses or peptones, meat juice, etc. 

Certain food substances have a distinctly stimulating action at 
all times. The various condiments possess a local action of this 
kind upon the alimentary organs, but not a general or systemic ac- 
tion. The latter stimulation, manifested especially upon the nerve- 



24 FOODS AND FOOD PREPARATIONS 

muscular apparatus, is derived from such substances as strong beef 
extracts, coffee, tea, and alcohol, all of which at times are of great 
service in the dietetic treatment of disease. The effect of sugar as a 
stimulant to relieve muscular fatigue has been described in the pre- 
vious section. 



ECONOMIC VALUE OF FOOD 

It is not within the scope of this work to discuss the details of 
the economic value of food, but brief reference to one or two facts 
will emphasise the importance of this topic. 

It is estimated that the annual cost of food production in the 
United States is at least three billion dollars, and the cost of pro- 
duction must be doubled in estimating the price paid by the con- 
sumer. 

Naturally, many attempts have been made to tabulate the cost of 
feeding large bodies of men employed by contract, or patients in 
hospitals and institutions. Some of these studies have been con- 
ducted with great care, but on a comparatively small scale, as in the 
case of the economic diets of the French factory operatives in Mas- 
sachusetts, the penny dinners furnished to London school children, 
and the researches made by Mrs. Richards and Miss Talbot upon 
pupils at the University of Chicago. Calculations upon a much 
larger scale are available as a basis for the supply of armies and 
navies. (See the section upon Diet for the Army and Navy.) 

The economic value of food cannot be estimated exclusively 
from its weight, and, as suggested by Williams, a pound of biscuit 
may contain as much fuel as a pound of beefsteak, and yet the body 
may be able to assimilate more of the beefsteak and derive more 
energy therefrom ; and it is the chemical processes of Nature which 
convert such substances as grass, which are not assimilable by the 
human organism, into the flesh of the ox, which is readily digested 
by man. 

It is economical in employing large bodies of men at manual* 
labour to feed them well, for they will do much more work propor- 
tionately. 

Carbohydrates check albuminous waste, and, like fats, yield both 
heat and mechanical work ; hence good bread, sugar, and potatoes 
are all economical foods for the labourer. Unlike the other classes 
of foods, however, they do not produce brawn, and do not enter into 
the actual structure of the tissues to any great extent, although the 
carbohydrates may be found existing as glycogen in some of the 
tissues, like the muscles and liver. In general, they seem to be 
more easily metabolised than fats or proteids. Assuming 3,500 
calories as the necessary daily standard for a labourer, one pound 
of flour yields 0.11 pound of protein and 1,650 calories; a pound of 



ECONOMIC VALUE OF FOOD 



25 



dried beans yields 0.22 pound of protein and 1,590 calories ; but cab- 
bage yields only 0.02 protein and 150 calories per pound, and oranges 
0.01 protein and 160 calories. 



Atwaters Table of Digestibility of Nutrients of Food Materials 



In the Food Materials Below 



Meat and fish 

Eggs--- 

Milk 

Butter 

Oleomargarine . . . 

Wheat bread 

Corn (maize) meal 

Rice 

Peas 

Potatoes 

Beets 



OF THE TOTAL AMOUNTS OF PROTEIN, FATS, AND 

CARBOHYDRATES THE FOLLOWING PERCENTAGES 

WERE DIGESTED \ 




Calculated Coefficients of Digestibility of Nutrients in Different Classes 

of Foods 

Standards used in calculations by the U. S. Department of Agriculture. 





Protein. 


Fats. 


Carbohydrates. 


Animal foods 


Per cent. 
98 
85 

80 


Per cent. 

97 
90 

90 


Per ce&it. 
IOO 


Cereals and starches 


98 
IOO 

95 


Sugars 

Vegetables and fruits 


g 



Percentage of Nutrition in Various Articles of Food (Moss) 



Raw cucumbers 2 

Raw melons 3 

Boiled turnips \\ 

Milk 7 

Cabbage 7^ 

Currants 10 

Whipped eggs 13 

Beets 14 

Apples 16 

Peaches 20 

Boiled codfish 21 

Broiled venison 22 

Potatoes 22^ 

Fried veal. . 24 

Roast poultry 26 



Raw beef. 26 

Raw grapes 27 

Raw prunes 29 

Boiled mutton 30 

Oatmeal porridge 75 

Rye bread 79 

Boiled beans 87 

Boiled rice 88 

Barley bread 88 

Wheat bread 90 



Baked corn bread 
Boiled barley 

Butter 

Boiled peas 

Raw oil 



26 



FOODS AND FOOD PREPARATIONS 



Atwaters Table for Nutrients and Potential Energy in Dietaries of 

Different People 



Sewing girl, London — wages 93 cents (3s. 

" qd.) per week 

Factory girl, Leipsic, Germany — wages 

$1.21 per week 

Underfed labourers, Lombardy, Italy — 

diet mostly vegetable 

Trappist monk in cloister, very little exer- 
cise — vegetable diet 

Miners at severe work, Germany 

Brickmakers (Italians at contract work), 

Munich 

Brewery labourer, Munich, very severe 

work, exceptional diet 

German soldiers, peace footing 

German soldiers, war footing 

German soldiers, Franco-German War — 

extraordinary ration 

Other factory operatives, mechanics, etc., 

Massachusetts 

Glass blowers, East Cambridge 

Private well-to-do family : 

Food purchased 

Food eaten 

College students from Northern and East- 
ern States — boarding: 

Food purchased 

Food eaten 

Club, two dietaries of the same club : 

Food purchased 

Food eaten 

College football team 

Teamsters, marble workers, etc., with hard 

work, Boston, Mass 

Brickmakers, Massachusetts 

United States Army ration 

United States Navy ration 





NUTRIENTS. 




Protein. 


Fats. 


Carbo- 
hydrates. 


Total. 


I 

1 Grins. 


Grins. 


Grms. 


Grms. 


\ " 


33 


316 


402 


52 


53 


30I 


406 


82 


40 


362 


484 


68 
133 


n 
113 


469 
634 


548 
880 


187 


117 


675 


959 


223 
114 

134 


113 
49 

58 


909 

480 
489 


1,245 

633 
681 


157 


285 


331 


773 


127 
95 


186 
132 


531 
48 1 


844 

708 


129 

128 


183 
177 


467 
466 


779 
77i 


161 

138 


204 

184 


680 
622 


1,045 
944 


115 
104 

181 


163 
136 
292 


480 
421 

557 


738 

661 

1,030 


254 
180 

120 

143 


363 
365 
161 
184 


826 

1,150 

454 

520 


i,443 

1,695 

735 

847 



Potential 
energy of 
nutrients. 



Calories. 
1,820 
1,940 
2,192 

2,304 
4,195 

4,641 

5,092 
2,798 
3,093 

4,652 

4,428 
3,590 

4,146 
4,082 



5,345 
4,827 

3,874 
3,417 
5,742 

7,804 
8,848 

3,85i 
4,998 



The actual cost of elementary foods naturally varies with the 
market, locality, season of the year, and other considerations. For- 
tunately, however, many foods which furnish most nutriment are 
among the cheapest and least variable in price. Breadstuff's, for 
instance, which may easily furnish one third of the total nutrients 
required, do not vary greatly in price, and the increase in cost of any 
diet depends more upon the higher price of green vegetables, fruits, 
and the better cuts of meats. Hence, when it is necessary to reduce 
the cost of living, peas, beans, oatmeal, and flour may be economically 
used to supply protein. Sugar, rice, pork, cornmeal, and potatoes 
all supply fuel (energy) at small expense. If variety rather than 
cheapness is desired, it is found in the use of green vegetables, fresh 
fruits, butter, eggs, and the better cuts of meat. In illustration of 



ECONOMIC VALUE OF FOOD 



27 



these principles are the three following tables from nutrition in- 
vestigations conducted by Isabel Bevier at Pittsburg, Pa. (U. S. 
Department of Agriculture Bulletin 52, 1898): 

Cost per Pound and Amounts and Fuel Value of the Digestible Nutrients 
in 1 Pound and in 10 Cents Worth of the More Important Food 
Materials used in a Dietary Study of a very Poor Polish Mill-worker's 
Family in Pittsburg, Pa. 



Kind of Food 
Material. 



Actual 

icost per 

pound. 



Beef: 

Stew meat 

Round 

Bologna sausage 
Pork: 

Ham, boiled. . . 

Head-cheese.. . 
Fish, herring, 

smoked 

Eggs 

Butter 

Milk 

Flour 

Oatmeal 

Bread 

Sugar, coffee. . . . 

Beans 

Potatoes 



Cents. 

5-o 
" 9 
4 



NUTRIENTS AND ENERGY IN I POUND 



D -. ■ t- . Carbohy- Fuel 

Protein. Fat. ^^ yalue> 



Pound. 

O.176 
.202 
.176 

.178 
.183 

•339 
.126 
.010 
.031 
.096 

•133 

.078 

'.178 
.013 



Pound. 

O.073 
121 
I 9 I 

359 
233 

145 

089 

843 
025 
010 
064 



016 



Pound. 



O.058 
•730 
.669 
•532 
•954 
.561 
.130 



Cat. 

635 

885 

1,130 

1,845 
1,325 

1,245 
6lO 

3,575 
270 
1,580 
1,760 
i,i35 
i,775 
1,442 
265 



NUTRIENTS AND ENERGY IN IO 
CENTS' WORTH. 



Protein. Fats. Carbohy- Fuel 
drates. value. 



Pound. 
O.15 

14 
20 

*9 

27 

25 
06 

33 
09 

03 
13 



03 



Founds. 



Pound. '• Cal. 

0.35 ; 1,270 

23 995 

19 1,205 



982 

1,555 

2,105 
430 

1,400 
970 
4,385 
3,520 
3,340 
3,010 

2,495 
2,420 



Cost per Pound and Amounts and Fuel Value of the Digestible Nutrients 
in 1 Pound and in 10 Cents Worth of the More Important Food 
Materials used in a Dietary Study of a Lawyer s Family in Good 
Circumstances 



Kind of Food 
Material. 



Beef: 

Ribs 

Round 

Shoulder clod. . 

Veal, chops 

Lamb, roast.. . . . 

Eggs 

Butter 

Milk 

Wheat flour 

Rolled oats 

Bread, baker's. . . 
Sugar, granulated 
Beans, dried. . . . 

Potatoes 

Oranges 



Actual 
cost per 
pound. 



Cents. 
I5.0 
I5.0 

11. 5 
18.0 

15-0 

13-3 
28.0 

3-9 
2.4 
2 



NUTRIENTS AND ENERGY IN I POUND 



Protein. Fat. <*J£T ™. 



10.0 



Pound. 

0.I20 

.196 

.184 

•159 
.164 
. 122 

.029 
. 122 
.144 

.081 



,l6l 
■OI3 
.OO8 



Pound. 
O.255 

047 
IO9 
084 
26l 
086 

868 
036 
012 
070 
on 

016 



Pound. 



O.046 

•729 
.702 

•517 
.966 

•593 
.120 

•043 



Cal. 
1,300 

565 
80O 
650 

1,405 
590 

3,665 
29O 

1,635 
1,870 
I,l6o 

i,795 
1,470 

245 

80 



NUTRIENTS AND ENERGY IN IO 

cents' WORTH. 



Protein. Fat. <**£»" J™ 



Pound. 
O.08 

13 
16 
09 
II 
09 

o- 

51 

23 

1 6 

38 
09 



Pound. 

O.I7 
.03 
.IO 
.05 
•17 

.c6 

•3i 
.09 
.05 
. n 
.02 

.04 



Pounds. 



Cal. 
865 

375 

700 

360 

935 

445 

1,310 

75o 

6,805 

3,oi5 

2,365 

3,595 

3,5O0 

1,645 

So 



28 



FOODS AND FOOD PREPARATIONS 



Summary of Dietary Studies here reported with Averages of Studies made 
Elsewhere. Quantities per Man per Day 





Cost. 


Protein. 


Fats. 


Carbohy- 
drates. 


Fuel 
value 




Cents. 
21 
13 
9 
22 
20 
16 

25 
20 


Grms. 
91 

85 

77 
147 
112 

94 
104 
103 


Grms. 

145 

IO4 

90 

173 
144 

121 
125 
I50 


Grms. 
38o 
307 
314 
683 
368 

385 
423 
402 


Cat. 
3,280 

2,575 
2,440 
5,010 
3.305 
3,085 

3.325 
3.465 




Dietary of a mill workman's family 

Dietary of a boiler tender's family 

Dietary of a house decorator's family 

Dietary of a glass blower's family 

Average 14 dietaries of professional men's families 
Average 14 dietaries of mechanics' families 



The following table is from the U. S. Department of Agriculture 
Bulletin No. 91, 1900, and summarises dietetic studies made in widely 
different parts of the United States : 

Cost, Nutrients, and Fuel Value of Food per Man per Day in Dietary 
Studies in Urbana and Elsewhere 



Cost of 
food. 



Protein. 



25.O 



22.3 



Teacher's family, Illinois : Cents. 

Food purchased 27.0 

Food wasted j .... 

Food eaten .... 

Professional men, Connecticut, average 
of 9 dietaries : 

Food purchased 

Food wasted 

Food eaten 

Professional man's family, Pennsylva- 
nia : 

Food purchased 

Food wasted , 

Food eaten 

Teacher's family, Indiana : 

Food purchased 

Food wasted 

Food eaten 

Proposed standard for man with little 

muscular work (Atwater) 

Mechanics' boarding club, Illinois : 

Food purchased 

Food wasted 

Food eaten 

Mechanics' families, Connecticut, av- 
erage of 9 dietaries : 

Food purchased 

Food wasted 

Food eaten 

Mechanic's family, Indiana : 

Food purchased 

Food wasted 

Food eaten 



Fats ! C f rboh y- 
drates. 



23.O 



26.O 



Grms. 
124 

23 
IOI 



IIO 

3 
107 



98 

7 

9i 

in 

5 
106 

112 

128 

11 

117 



113 

7 

106 

106 
16 
90 



Fuel 
value. 



Nutritive 
ratio. 



45 
113 


4 b 
441 


136 

7 
129 


442 

5 
437 


155 
10 

145 


396 

16 

380 


no 

8 

IC2 


349 

9 

340 


171 

25 
I46 


392 
379 


153 

II 

142 


420 

14 
406 


157 

23 

134 


475 

67 

408 



Grms. Calories. 

487 3,975 
700 

3,275 



3,53o 

100 

3.430 



3,465 

185 

3,280 

2,910 
130 

2,780 

3,000 

3,720 

330 

3,39° 



3,605 

185 

3,42o 

3,840 

555 
3,285 



1 : 6.9 



1 : 6. 



1 : 7. 



1 = 5-4 
t: 5-5 



1 : 6.1 



1 : 6.9 



1 : 7.9 



NUTRITION. ANIMAL AND VEGETABLE FOODS COMPARED 29 





Cost of 
food. 


Protein. 


Fats. 


Carbohy- 
drates. 


Fuel 
value. 


Nutritive 
ratio. 


Mechanic's family, Tennessee : 


Cents. 
16.O 


Grms. 
II 9 

9 

IIO 

103 

3 
100 

125 


Grms. 
224 

14 
2IO 

I44 

6 

138 


Grms. 

455 

43 

412 

43i 
6 

425 


Calories. 

4,435 

345 

4,090 

3,530 

95 

3,435 

3,5oo 




Food wasted 




Food eaten 




i:8.I 


Mechanic's family, New Jersey : 


28.O 




Food wasted 




Food eaten 




i : 7.4 

i : 6.8 


Proposed dietary standard for man 
with moderate work (Atwater) 





In a study by E. F. Ladd, made in 1900, of eleven women students 
in North Dakota who averaged nineteen years of age, the result was 
as follows : 



Food Eaten. 


COMPOSITION AND FUEL VALUE OF FOOD 
PER DAY. 


PER WOMAN 


Protein. 


Fats. 


Carbohydrates. 


Fuel value. 


Animal food 


Grammes. 
31 

33 


Grammes. 

94 

5 


Grammes. 

5 

355 


Calories. 
1,025 
1,635 


Vegetable food 




Total food 


64 


99 


360 


2,66o 







A similar study by Atwater made upon the diet of women stu- 
dents in Connecticut shows a consumption of 84 grammes protein, 
128 grammes fat, and 264 grammes carbohydrate, yielding 3,015 
calories. The accepted standard for woman at light muscular work 
calls for 90 grammes of protein and a total fuel value of 2,400 calories 
of energy, hence both these dietaries were deficient in protein, al- 
though the total fuel value was considerably above the standard 
requirement. This shows that a considerable departure from normal 
dietetic standards is not incompatible with health. 



NUTRITION. ANIMAL AND VEGETABLE FOODS 
COMPARED 

The study of nutrition, or the problem of tracing the food prod- 
ucts, after absorption from the alimentary canal, through the various 
changes which they undergo prior to elimination in the compara- 
tively simple forms of waste matter — namely, water, urea, and C0 2 — 
has long baffled the science of physiological chemistry. There are, 
however, general principles that are established both by analysis and 
clinical observation which concern the effect upon the system of 
these different classes of foods. 

Among the lower animals the effect upon the whole system of 
modifications in nutrition produced by special methods of feeding 



30 FOODS AND FOOD PREPARATIONS 

are much more striking than in man, as, for example, the feeding of 
the queen bee, and of draught horses as compared with racers. 

Animal food is believed by many to make the blood rich in fibrin 
and corpuscles, and to increase the mineral salts, especially the phos- 
phates ; it both repairs the old and forms new tissue ; it improves the 
condition of the muscles, which are made firmer than they are 
through a vegetable diet, and it favours the reduction of stored-up 
or surplus fat. Under som^ conditions it may produce a part of the 
body fat, although most of it is derived from other sources. (See 
Obesity.) It also increases the quantity of urates, phosphates, sul- 
phates, and urea normally present in the urine, and tends to make the 
fluids of the body somewhat more acid or less alkaline. 

Bauer (Dietary of the Sick) says : " The functional activity and 
resisting power of the organism seem to be essentially connected 
with the presence of an ample supply of albumin." 

Animal food requires a considerable quantity of oxygen for its 
complete combustion, and a diet of this nature increases the demand 
for oxygen and favours its consumption. Meat in general has a more 
stimulating effect upon the system and is more " strengthening " 
than vegetable food, and it gives rise to sensations of energy and 
activity. A meal consisting of meat remains an hour or two longer 
in the stomach than a purely vegetable meal. It seems to satisfy the 
cravings of hunger, bulk for bulk, to a greater extent and for a 
longer time than vegetable food, and a man can live longer upon ex- 
clusive nitrogenous food than upon exclusive carbonaceous food. 
Animal food occupies less space in the stomach, and is more portable 
than vegetable food. Moreover, albuminous foods can be eaten 
longer alone without exciting loathing, as a rule, than can fats, 
sugars, or even some pure starches. In fact, there is a constant 
tendency to eat too much meat, and when its effects are not counter- 
balanced by free outdoor exercise, it produces an excess of waste 
matter which accumulates and causes biliousness, and sometimes 
lithiasis, gout, etc. A carbonaceous diet taxes the excretory organs 
to a lesser degree than animal food. 

Sir Henry Thompson says : " It is a vulgar error to regard meat 
in any form as necessary to life." Nitrogenous food man must 
have, but it need not necessarily be in the form of meat, which " to 
many has become partially desirable only by the force of habit, and 
because their digestive organs have thus been trained to deal with it." 

This is but partially true, for the training has become so strongly 
a matter of heredity through many centuries that those who possess 
it are certainly in better health for a reasonable allowance of meat in 
their dietary, and many primitive savage tribes, have always subsisted 
largely upon meat. Errors in diet are far more common on the side 
of excessive meat eating than the eating of too much vegetable food, 
especially among civilised communities. In the temperate zones an 



NUTRITION. ANIMAL AND VEGETABLE FOODS COMPARED 3 1 

increase in prosperity, together with the improvements made in the 
methods of preparing and preserving meat as well as those in breed- 
ing cattle for market purposes, tend to increase the habit of meat 
eating. The common estimate, in which meat should occupy one 
fourth and vegetable food three fourths of a mixed diet, is over- 
stepped by many persons with whom the proportion may be two or 
three to four. 

The proper association of different foods always keeps healthy 
men in better condition than too long continuance of any selected 
diet system. 

Sir Henry Thompson, in speaking of the advantages of a well- 
proportioned diet, says : " A' preference for the high flavours and 
stimulating scents peculiar to the flesh of vertebrate animals mostly 
subsides after a fair trial of milder foods when supplied in variety. 
. . . The desire for food is keener, the satisfaction in gratifying ap- 
petite is greater and more enjoyable on the part of the general light 
feeder, than with the almost exclusively flesh feeder. . . . Three 
fourths at least of the nutrient matters consumed are from the ani- 
mal kingdom. A reversal of the proportions indicated — that is, a 
fourth only from the latter source, with three fourths of vegetable 
produce — would furnish greater variety for the table, tend to main- 
tain a cleaner palate, increased zest for food, a lighter and more 
active brain, and a better state of health for most people not en- 
gaged in the most laborious employments of active life." 

This comment is more applicable to the upper classes in England 
than in this country, where more attention is given to the cultivation 
and cooking of fresh vegetables and the preparation of vegetable 
products. 

Letheby wrote : " The best proportions for the common wants of 
the animal system are about nine of fat, twenty-two of flesh-forming 
substances, and sixty-nine of starch and sugar." An average of 
eighty-seven practical dietary studies made by the U. S. Department 
of Agriculture showed that the food consumed was 45 per cent of 
animal and 55 per cent of vegetable origin. 

Meats which are deficient in fat are usually eaten with added fat. 
Thus bacon is eaten with veal, liver, and chicken, and most fish are 
cooked with butter or oil. Similarly, butter, eggs, or cream are 
mixed with amylaceous foods, such as rice, sago, potatoes, etc., which 
are lacking in fat, and cheese containing fat is added to macaroni. 
Bacon is added to beans, and pork to greens. 

" Whenever one kind of food is wanting in any particular con- 
stituent, we invariably associate it with another that contains an ex- 
cess of it " (Letheby). 

If a labouring man is allowed an ordinary meat ration he requires 
in addition, to obtain his requisite carbon, of fat 346 grammes, and 
of starch 596 grammes (Voit). But he would soon tire of such a 



32 FOODS AND FOOD PREPARATIONS 

quantity of either of these two food classes alone, and he does better 
to eat some of each. As pointed out by Voit more than thirty years 
ago, the available vegetable nutrients are so enclosed in cellulose or 
woody fibre as to render their absorption difficult. Vegetable food 
eaten in excess is liable to induce intestinal fermentation, which ex- 
cites peristalsis, and as the intestine of man is much shorter than that 
of herbivores, this class of food does not have time for complete 
absorption. 

The carnivorous animal fed upon lean meat alone requires a daily 
supply equal to one twentieth of his body weight, but if a little fat 
. be added he needs much less. 

Animal food is often said to be more stimulating to the passions 
than vegetable food, and the general character of carnivorous ani- 
mals is more savage than that of herbivorous, although the angered 
bull is as fierce as any carnivore. It is doubtful, however, whether 
this is attributable so much to their different diet as to many other 
conditions which have contributed through the survival of the fittest 
to their differentiation. Carnivorous animals are obliged to work 
and fight for their food ; they obtain it at uncertain and infrequent 
intervals, often when made ravenous by long periods of fasting. 
Herbivorous animals, on the contrary, always have their food at 
hand, obtainable with no labour other than that of eating. The 
Polynesian warrior is more ferocious at times on a diet of plantains 
than the Eskimo, who eats nothing but fish, meat, and fats. 

Formerly nitrogenous foods were believed to furnish the chief 
supply of energy for the body, especially in the production of mus- 
cular force ; but the experiments of Parkes and others made some 
thirty years ago did much to modify this theory, and it is now be- 
lieved that the chief value of nitrogenous food stuffs lies in tissue 
formation in distinction from force production, which is maintained 
by the hydrocarbons. Some energy is undoubtedly derived from 
nitrogenous material, for no molecular rearrangement or chemical 
reaction can take place without altering the balance of energy, but 
the force produced by combustion of proteids is insignificant in com- 
parison with their other uses. In support of this statement, the fol- 
lowing facts may be cited as abundantly proved : I. Severe and long- 
continued muscular exercise does not cause the quantity of urea in 
the urine to be materially increased. Urea represents the ashes of 
proteid material, and increase in its quantity is due to a more active 
oxidation of animal food, not necessarily to tissue waste. 2. Mus- 
cular exercise, on the contrary, does result in a great increase in the 
amount of C0 2 eliminated from the lungs, which is primarily derived 
from the combustion of hydrocarbons. 3. Isolated muscles made to 
contract by artificial stimulation when contained in vacuo under a 
bell glass have been shown to produce by their activity large quanti- 
ties of C0 2 , but no urea. 4. Prolonged muscular exercise or extra- 



NUTRITION. ANIMAL AND VEGETABLE FOODS COMPARED 33 

ordinary exertion can be maintained upon a diet of starchy foods 
and fat without meat ; and during the period following the exertion 
the urea is not increased beyond a degree which is readily accounted 
for by a slight wasting of the nitrogenous tissues of the body. 

A man cannot perform more actual muscular labour upon an ex- 
clusive diet of animal food than of starchy food. He requires abun- 
dant animal food to replace the general wear and tear of muscular 
tissue, but the energy for muscular contraction is not derived from 
nitrogenous food, but from carbohydrates, the former being used 
merely to keep the muscles in a state of healthful equilibrium. 
He who is physically feeble and who lacks muscular power cannot 
restore that power by an exclusive nitrogenous diet. A man fed 
upon nitrogenous diet without vegetable food may not work as well 
in daily labour as when given a fair proportion of the latter ; but, on 
the other hand, he is better fitted for sudden arduous exertion than 
are exclusive vegetable feeders. 

A mixed diet is therefore the only rational one for man, and it is 
useless to reason otherwise from analogy with the lower animals. 
The ox is strong and performs daily labour upon a grass diet, but he 
extracts a large proportion of nitrogen from such food which man's 
feebler digestive organs do not enable him to do. The proportion 
of proteid to carbohydrate is 1 to 4.7 in such food. The horse is fed 
upon oats when it is desired to increase his spirit and activity, and 
he derives more nitrogen from them than does man from his oatmeal. 
The lion derives great strength from purely nitrogenous food, but 
even when trained he is wholly unfit for the continuous exertion that 
herbivores can endure. 

The northern Eskimo, who has absolutely no starchy or saccha- 
rine food, eats fat with his proteid diet, and is therefore enabled to 
acquire energy to resist extreme cold and to take very long and 
fatiguing sledge journeys ; yet he is no stronger, nor as strong, as 
the Central African negro, who lives upon a diet of manioc and plan- 
tains, without meat. 

" Some food rich in protein will be found in the daily diet of all 
peoples. The Mongol eats with his rice, which is largely starch, 
small quantities of fish, fish eggs, and goose livers, but for his supply 
of proteid material he relies on his different preparations of bean 
cheese and on soja sauce made from the soy bean. The Mexican, 
whose supply of meat is scanty and of a poor quality, uses the native 
bean or frijole at almost every meal, made into a stew with vegetables 
and perhaps shreds of sun-dried beef, well spiced with the chili or 
red pepper " (Mary Hinman Abel). 

Man is an animal of extraordinary adaptability to his environ- 
ment, and one must be consequently guarded in making dogmatic 
statements in regard to his diet, and such observations as the above 
must be taken as applying only generally, for it seems possible for 



34 FOODS AND FOOD PREPARATIONS 

either class of foods to supplement to some extent the functions of 
the other. This fact is illustrated in disease as well as in health. 
For example, in the earlier stages of diabetes sugar is formed from 
farinaceous and saccharine food almost exclusively, but in the ad- 
vanced stages, when these substances are withheld, it can undoubtedly 
be made from proteid material. 

The combinations of foods which are by analysis shown to con- 
tain quantities of proteids, starch, and fat, have a very different effect 
in overtaxing the digestive organs according to the particular form 
in which their ingredients exist. 

It is a popular belief that meat requires more effort for digestion 
than starchy food, but in health this is probably not true, provided 
both varieties of food are taken in correct proportion, for it certainly 
would be a strain upon the digestive system to be obliged to derive 
all the carbon needed from an exclusive meat diet, just as it over- 
taxes the alimentary canal to obtain sufficient nitrogenous material 
from an exclusive vegetable diet. It cannot be said didactically that 
a piece of beef is more or less digestible than a potato, and that it 
taxes the energies of the digestive organs to a greater extent, 
although it is more completely assimilated and leaves less waste in 
the intestine. The whole question devolves upon a true balance of 
the ingredients of a mixed diet. As regards the actual complexity 
of the digestive processes of the several classes of food, there is but 
little difference : both starches and proteids pass through interme- 
diate stages on the way to the formation of their completed products, 
and fermentation cannot be said to present greater difficulty in the 
one case than in the other. For man, certainly, Nature never in- 
tended that all the nutrition of the body should be derived from any 
one class of food stuff which would require the use of certain di- 
gestive juices, and imply the disuse of others which are normally 
present. 

A diet of animal food is much less fattening than a vegetable 
regimen or than carbohydrates with a fair proportion of fats, but a 
stout man does not endure fatigue, or even starvation, better than 
a lean man. On the other hand, to increase the proteid substances 
of the body an albuminous diet with but little carbohydrate is neces- 
sary. Men, unless greatly emaciated, have a reserve store of energy 
in their bodies sufficient to maintain their animal heat and keep them 
alive for from seven to nine days, and this is true whether they have 
been meat eaters or vegetarians. Storage of fat will help them out in 
emergencies, but if it has been overdone — i. e., if there is too much 
fat in the tissues — they may be weakened by it and, although they 
have the material for force production on hand, they are unable to 
utilise it, and are worse off than if they were spare. (See Obesity 
and Leanness.) 

Bauer says : " The material effects of albumin and of fat in the 



VEGETARIANISM 35 

system are in a certain sense opposed, for the former increases the 
tissue waste and secondarily the oxidation, while fat induces the op- 
posite effects." When the organism is in health albumin constitutes 
upon the average about 10 per cent of the body weight and fat about 
1 6 per cent, but these proportions may vary within wide limits. 

Animal food is easily cooked, requiring less fuel than vegetable 
food, and in the process develops more flavour than does vegetable 
food. 

VEGETARIANISM 

In regard to an exclusive or almost exclusive vegetable diet for 
man, the universal experience has been that while it may keep him 
in apparent health for some time, it eventually results in a loss of 
strength and general resisting power against disease, which becomes 
evident after some months, if not before. 

Of vegetarianism Bauer says : " The beneficial effects of vege- 
tarianism certainly do not depend on the fact that its followers take 
no meat, and still more no animal food, but on their giving up their 
former bad habits." 

No doubt much of the alleged benefit of vegetarianism is due to 
the greater freedom of action of the bowels, induced by the use of 
bran bread and other coarse articles of food. 

It is impossible to subsist for any length of time on a diet which 
does not contain a considerable quantity of nitrogen, which con- 
stitutes so important an element in the composition of the great 
majority of structures of the body, and, in fact, of protoplasm itself. 

Attempts have from time to time been made, for economic rea- 
sons, to furnish large bodies of labouring men, employed by con- 
tract or otherwise, with a purely vegetable diet ; but this diet is 
found to defeat its own ends, in that the maximum of labour can- 
not be maintained by men who are fed exclusively on vegetable 
food, although some carbohydrates are essential. It gradually in- 
duces a condition of muscular weakness and languor with disincli- 
nation for either physical or mental work. In support of this state- 
ment Vigsford relates that for the construction of a railway from 
Paris to Rouen, English and French workmen were employed. 
The former did one third more work than the French, until in the 
French diet roast beef, as in the diet of the English, was substituted 
for bouille and soup, after which the work done by the two gangs of 
men was equalised. 

In referring to graminivorous people, like the Bengalese, Cham- 
bers wrote : " If required to exert themselves in any unusual way 
when food is deficient, they simply die. The reason is evident — 
they have been living on their own tissues, and the small quantity 
of albuminous matter in grain is a long time in building them up 
again, so that for weeks, or even months, their muscles are in a state 



36 FOODS AND FOOD PREPARATIONS 

of atrophy." It is found, too, that their food must be very gradu- 
ally altered if they are to change to a mixed diet. 

Animal food in some form must be regarded as absolutely essen- 
tial for all vigorous races. When the diet of enthusiastic " vege- 
tarians " is carefully investigated it is found that the strictly hydro- 
carbonaceous food is supplemented by such articles as milk, eggs, 
etc., which are used in cooking or in other ways, although the con- 
sumption of nitrogenous food may appear very much restricted. 

It is believed by Giibler and others that an exclusive vegetable 
diet eventually develops an atheromatous condition of the arteries, 
on account of the large proportion of mineral salts which thus enter 
the blood, but the evidence of this is not convincing. It is also 
claimed that a vegetable diet favours the deposition of mineral salts 
in different parts of the body, as phosphatic stone, gravel, and the 
tartar on the teeth, and that living upon coarse cereals alone makes 
the skin rough, and the individual dull, heavy, and ill-tempered. 

While it is quite true that some kinds of vegetables contain a large 
proportion of nitrogenous substance, it exists in a form in which 
it is less easily assimilated than animal proteid. In vegetable foods 
nitrogenous materials are more or less closely mingled with starch. 
Cellulose itself is often very tough and insoluble in the digestive 
fluids, so that as large a proportion of protein as 17 per cent may be 
wasted, while not over 3 per cent of the proteid of animal food re- 
mains undigested (Yeo). This is an important illustration of the 
fact that one must not be guided by chemical composition alone in 
selecting the proper dietary for man, but the question should rather 
depend upon the actual nutrient value of the food when absorbed. 
A food in its ultimate analysis may yield the necessary chemical 
ingredients for a nutritious diet, and yet from imperfect digestibility 
it may prove of little service for actual nutriment. 

There are many facts in Nature in addition to those already 
discussed which indicate without doubt that man from his earliest 
prehistoric days has been omnivorous, adapting himself to his sur- 
roundings and eating, in his primitive condition, whatever his envi- 
ronment afforded, with least expenditure of labour to obtain it, now 
vegetable, now animal food. This is shown in the structure of the 
teeth in prehistoric skulls, and in the length of the alimentary canal 
and character of the digestive organs and secretions as at present 
existing. 

The ancient Britons are known to have subsisted largely upon 
acorns, berries, roots, leaves, etc., but other primitive tribes ate fish, 
shellfish, and, when they could kill it, game. 

A brief glance at the dietetic habits of the more primitive tribes 
of mankind at present living shows that no arguments can be drawn 
from them as to the advantages of any particular class of foods. 

Many savage tribes to-day live very largely upon vegetable food, 



WATER 37 

although an exclusive vegetable diet is almost unknown among 
them, and most of them eat meat whenever they can obtain it, or 
they supplement their food by nitrogenous articles, such as milk, 
eggs, fish, and insects of various kinds. Even the Chinese and 
Japanese, who subsist principally upon simple farinaceous food, such 
as rice, eat also eggs, fish, pork, and chicken. On the other hand, 
there are tribes of men inhabiting very hot countries who eat con- 
siderable quantities of meat, as, for example, the Nubian Arabs 
and Abyssinians. Some natives along the Congo subsist solely upon 
fruits (plantains) and insects. The Mongolian lives by his herds — 
upon milk products and meat — bread being scarcely known to him. 
The Australian savage is omnivorous, and, having no cereals, he 
subsists upon berries, beans, pith, nuts, honey, larvae, ants, etc. The 
Papuan Islanders live chiefly upon sago, fish, and fruits. The New 
Caledonians were formerly cannibals, but are now vegetarians by 
preference, and prefer to trade their pigs and goats with passing 
ships rather than to eat them. 

Vegetarianism in former times has had many famous advocates. 
Shelley was a vegetarian, so was Jean Jacques Rousseau, and Gold- 
smith also at one time. There is a vegetarian society in England 
which has established restaurants in London, Manchester, and sev- 
eral other localities. In London there are upward of 4,000 mem- 
bers of this society. There is a similar organisation in this country. 
The creed of esoteric Buddhism has induced some persons in this 
country to adopt vegetarian habits, but few of them adhere to them 
strictly or for long. 



THE CLASSES OF FOODS-I. WATER 

It is estimated that water composes about 70 per cent of the 
entire body weight, and it is an almost universal solvent. Its im- 
portance to the system, therefore, cannot be overrated. The elastic- 
ity or pliability of muscles, cartilages, and tendons, and even of 
bones, is in great part due to the water which these tissues contain. 
As Solis-Cohen says, " the cells of the body are aquatic in their 
habits." The amount of water required by a healthy, man in twenty- 
four hours is, on the average, between 65 and 70 ounces, besides 
about 20 ounces taken in as an ingredient of solid food, thus making 
a total of 85 to 90 ounces. The elimination of this water is divided 
as follows : 28 per cent through the skin, 20 per cent through the 
lungs, 50 per cent through the urine, 2 per cent through other secre- 
tions and the feces. This is, of course, a very general computation, 
for there is constant variation in the activity of different organs. 

A large proportion of the water is taken in the form of beverages 
composed chiefly of it, and by many persons they are substituted for 
plain water altogether. In some countries light wines, beer, and 



38 FOODS AND FOOD PREPARATIONS 

other fermented drinks wholly replace drinking water. This may be 
due to habit and custom, or to necessity from lack of pure natural 
water, but in all cases the quantity of water required to maintain the 
functions of the body in healthful activity remains the same, whether 
it be drunk pure or in beverages, or taken with succulent fruits and 
vegetables, or in milk, koumiss, etc. 

One of the most universal dietetic failings is neglect to take 
enough water into the system. 

Uses of Water in the Body. — The uses of water in the body may 
be summarised as follows : 

1. It enters into the chemical composition of the tissues. 

2. It forms the chief ingredient of all the fluids of the body and 
maintains their proper degree of dilution. 

3. By moistening various surfaces of the body, such as the mu- 
cous and serous membranes, it prevents friction and the uncomforta- 
ble symptoms which might result from their drying. 

4. It furnishes in the blood and lymph a fluid medium by which 
food may be taken to remote parts of the body and the waste mat- 
ter removed, thus promoting rapid tissue changes. 

5. It serves as a distributer of body heat. 

6. It regulates the body temperature by the physical processes of 
absorption and evaporation. 

All protoplasmic activity in cells ceases at once if they become 
dry. Elementary cells, such as the amoeba, cease to move, to digest, 
or to show any form of irritability or functional activity when dry, 
but if water be added to them their functions will be resumed, show- 
ing that they have been suspended and not necessarily destroyed. 

The taking of much water into the stomach by its mechanical 
pressure excites peristalsis. One or two tumblerfuls of cold water 
taken into an empty stomach in the morning on rising favour evacua- 
tion of the bowels in this way. The water, moreover, is quickly ab- 
sorbed and temporarily increases the fulness of the blood vessels. 
This promotes intestinal secretion and peristalsis. The increased 
activity of the lower bowel is explained in this way rather than by 
the idea that the water itself reaches the colon and washes out its 
contents. 

Lukewarm water acts as an emetic if drunk in large quantity. 
This action fails above 95 F. and below 6o° F., and is most efficient 
at about 90 F. 

Purity of Water. — Of recent years the importance of insuring 
the purity of drinking water has become more and more appreciated, 
and an intelligent public is now aroused to the absolute necessity of 
protecting their supplies of drinking water from contamination with 
sewage, decomposing animal matter, etc. So general has the interest 
in this subject become in this country that new laws are being 
passed constantly to protect the water supply of large cities and 



WATER 39 

towns. The subject is not confined to water alone, but includes ice 
as well, for many of the germs and organic impurities of water are 
not destroyed by freezing, and impure ice added to pure water con- 
taminates it. It has been very clearly proved that many infections 
may be conveyed through the agency of water ; among the most 
important of these are the germs of typhoid fever, dysentery, and 
cholera. Possibly, also, the germs of other diseases, such as tuber- 
culosis and diphtheria, can exceptionally be thus conveyed, should 
they obtain access to drinking water. Water may be further ren- 
dered unwholesome by moulds, ferments, and excess of decaying 
vegetable matter. (For water contaminated with lead, see Lead 
Poisoning.) Water from shallow wells and wells near drains, barn- 
yards, cesspools, or privies is unfit for drinking. 

Varieties of Drinking Water. — Water containing a moderate 
quantity of mineral salts, 4 or 5 grains to the gallon, is not to be 
regarded as impure, but the composition as well as the quantity of 
these salts affect its power as a solvent in the tissues, and may exert 
a very decided influence upon the digestive system when present in 
the proportion of 60 or 70 grains to the gallon. The mineral waters 
may contain much more. Water is usually unwholesome for drink- 
ing when derived from volcanic and basaltic mountain regions, and 
because of organic impurities it is bad in marshy regions. 

Hard and Soft Water. — An excess of lime salts and of other min- 
eral matters in water produces constipation, flatulence, indigestion, 
and favours the formation of calcareous deposits in various parts of 
the body. " Hard water " unites with soap and makes it less soluble, 
so that it is difficult to cleanse the hands with it. It also roughens 
the skin and dries the mucous membranes. By boiling, the hardness 
of water, which is due to the presence of earthy carbonates, is dimin- 
ished, for the carbonic acid, which aids in holding them in suspen- 
sion, is driven off. Water is also improved for drinking by filtering 
through a filter paper, or clean absorbent cotton on a funnel. Boil- 
ing the water does not precipitate neutral and alkaline salts, and a 
purgative action may still remain if they are present. Hard water 
is made more digestible by converting it into barley or oatmeal water. 
Water which contains sulphate of lime causes gastric distress and 
dyspepsia, and it may form calculi. " Soft water " is simply water 
which is free from objectionable salts. It is more wholesome than 
hard water. Hard and soft water have well-known characteristics in 
regard to their effect upon the cooking of food. Calcareous drink- 
ing waters have been believed to be factors in the development of 
goitre and cretinism, notably in Switzerland, but many cases occur 
in which such theory is untenable. 

Rain Water. — Next to clear mountain-spring water which has run 
through gravel and been well aerated, rain water at the close of a 
shower is the purest form of natural water, excepting where it has 



40 FOODS AND FOOD PREPARATIONS 

fallen through a very dusty or smoky atmosphere or has run over a 
dirty roof. The first drops of a shower carry down with them the 
impurities of the air, including traces of ammonia and nitric acid. 
No natural water possesses absolute chemical purity, but water col- 
lected at the end of a hard or long shower is very pure, having been 
distilled by previous evaporation. 

River water which has run over a rocky or gravel bed, and has 
been well aerated, is quite pure and assimilable if properly protected 
from sources of pollution. Free oxidation makes much organic 
matter harmless. Flowing water by oxidation and dilution becomes 
purified to a great extent of injurious organic matter, but is not 
necessarily deprived of living germs of contagion, such as those of 
typhoid fever or cholera, and the question whether their number and 
virulence is at all diminished in such water is still a matter of con- 
troversy. 

It is now so well recognised that the impurities of water which 
are chiefly dangerous to man are of organic germ origin that in 
examining water which is suspected of being the cause of a typhoid- 
fever epidemic a chemical analysis of the nitrates present, unaccom- 
panied by a proper bacteriological examination, is entirely useless. 

Distilled Water. — Distilled water is absolutely pure, but it has a 
flat or metallic taste from absence of air and salts. It is now ex- 
tensively furnished for drinking, and is largely in use on vessels at 
sea. Our modern naval vessels carry apparatus for its preparation. 
Distilled water has been recommended as a solvent for calculi, but 
it is of doubtful efficacy. It erodes lead pipes and cisterns. 

Filtered Water. — Filtration as employed to render drinking water 
more pure is a very delusive process, unless great care be taken as 
to the construction of the filter and the rate of filtration. Extensive 
experiments made at Providence, R. I., and Lawrence, Mass., have 
proved that the benefit of sand infiltration of city water results only 
when the filters are frequently cleaned. The sand layer should not 
be less than 30 centimetres thick, nor the rate of water flow fall 
below 100 millimetres per second. Frequent bacteriological ex- 
amination of the water should be made. Koch has shown that it 
is not the sand which " filters," but the layer of mud or slime which 
is deposited upon it and which retains bacteria. Hence the reason for 
not allowing filters to become clogged with mud in which germs 
multiply. During the Hamburg cholera epidemic of 1892, the neigh- 
bouring town of Altona suffered much less severely from the disease 
than did Hamburg, for, although the Altona water supply was con- 
taminated by Hamburg sewage, the water was thoroughly filtered. 
A great variety of patent filters have been devised, and they have the 
power of making water appear pure by decolourising it and remov- 
ing the larger organic particles and grosser impurities which it may 
contain, but it has been conclusively shown that the bed of a filter 



WATER 41 

which has been in use for a short time furnishes a favourable soil or 
culture medium for the development of germs, which increase very 
rapidly until they reach such numbers that they are washed out with 
the filtered water, rendering it much more injurious, in some in- 
stances, than it was before. Many of these germs are doubtless 
harmless, but if the microbes of infectious diseases once gain access 
to such a soil they multiply and become highly dangerous. 

Boiled Water. — Boiled water is antifermentative and antiseptic. 

The object of boiling the water which is to be used for drinking 
purposes, or in the preparation of food, is to free it from all organic 
impurities, and in some cases to precipitate salts of lime. There are 
no forms of germs, and there are no ferments which are not killed 
by a longer or shorter exposure to the temperature of boiling water. 
The process consists in the application of heat to water in sufficient 
degree to expand the air which it naturally absorbs and cause it to 
rise to the surface in bubbles of various sizes. If the water contains 
gases of decomposition they are expelled, and the odour is most 
foul just before the boiling point is reached ; later it passes off, show- 
ing when the water is fit to drink. When boiled water, cooled, is 
drunk it tastes " flat " or insipid, but it may be freshened by pour- 
ing it through the air from one vessel to another or by shaking it 
with air in a carafe. Water should always be boiled before being 
drunk if there is the slightest suspicion as to its purity. The 
population of the larger Chinese cities is exceedingly dense, and 
the water used by the inhabitants is impregnated with all manner 
of filth, but it is believed that the custom of the natives of drinking 
tea infused with boiling water, or even drinking hot water, pro- 
tects them to a great extent from the ravages of certain microbic 
diseases. 

The special dietetic uses of water will receive attention under the 
appropriate headings of different diseases. 

Water may be of service to eliminate waste in various renal dis- 
eases, gout, lithiasis, oxaluria, renal inadequacy, fevers, and infectious 
diseases. If imbibed too freely with meals it lessens the activity of 
the saliva and gastric juice. Water taken near the end of the gastric 
digestion of a meal (i. e., two or three hours after taking food) serves 
to dilute the contents of the stomach and wash it more easily into 
the intestine. If stomach digestion has been slow and feeble, so that 
the whole process has been greatly prolonged, the drinking of six or 
eight ounces of water, either hot or cold, two hours or more after 
taking food will facilitate its digestion. Water is highly useful in 
constipation, and it is more quickly absorbed from the stomach 
when the tension in the gastric vessels is low. 

It is imperatively needed after severe haemorrhage, or after the 
sudden loss of it from the system from any cause, such as the evacu- 
ations of cholera morbus, Asiatic cholera, etc. 
5 



42 FOODS AND FOOD PREPARATIONS 

It is to be restricted in dilatation of the stomach, the secretion of 
weak gastric juice, and sometimes, but not always, in diabetes insipi- 
dus, diabetes mellitus, ascites and other dropsies, anasarca, and in 
some forms of heart disease and obesity. 

The daily quantity of water ordinarily drunk varies between two 
and a half and four pints. About one and a half pint more is taken 
in the food, and four and a half or five pints are therefore lost 
through the emunctories. 

Foods which contain most water are milk and succulent fruits, 
such as grapes, oranges, grape fruit, lemons, watermelons, etc., and 
vegetables like the tomato, squash, and many others of tropical 
origin. All vegetables contain more water than meats, and many, 
but not all, ripe fruits contain more than vegetables. 

Excess of Water. — There is a remarkable tendency on the part 
of the blood to maintain an equilibrium as regards its own com- 
position, volume, and density. When a large supply of water is re- 
ceived in the alimentary canal and absorbed by the blood vessels, 
the blood is momentarily diluted and the blood pressure slightly 
raised, although the latter effect will depend upon the facility with 
which the blood vessels are dilated. The blood immediately dis- 
tributes the water thus absorbed, and the slightly increased pressure, 
as well as the diluted character of the blood, hastens the elimination 
of water from the various gland surfaces. The kidneys are particu- 
larly sensitive in this respect, and when in normal condition are the 
great regulators of the composition of the blood and, indirectly, of 
blood pressure by means of the elimination of water. Perspiration 
is increased. There is a tendency also for all the tissues to keep 
abundantly supplied with water ; a large amount of aqueous vapour 
is exhaled from the surface of the lungs, and the digestive secretions 
are increased in volume. The blood may subsequently become 
more dense than before, owing to the increased functional activity 
of different organs. More nutriment is absorbed and more car- 
bonic acid is exhaled, and urea and uric acid may be slightly 
increased. 

If very large quantities of water, or any fluids consisting chiefly of 
water, are imbibed throughout a long period, they tend to overwork 
the kidneys and produce various alterations in the tissues. Practi- 
cally, however, it seldom happens, excepting in some forms of gas- 
tric or intestinal disorder, and other instances mentioned above, that 
too much water is taken. When drunk in such fluids as beer, or di- 
luted liquors, the resulting disturbances of the system are attribu- 
table rather to other ingredients. 

Laymen are usually more willing to ascribe obesity to supposed 
excessive consumption of fluids than to overeating. They often say 
that they suppose water is " fattening." It is so only in the sense 
that it promotes tissue change or metabolism and washes away 



WATER 43 

waste matter, not in the sense that it is itself a storage substance, as 
fat is. 

Deprivation of Water. Water Starvation. — When water is with- 
held from the system for a considerable length of time its absence 
is first apparent in the secretions and excretions, and next in the 
various tissues of the body, the last of all being those of the nervous 
system. More than ten or twelve hours of abstention from drink- 
ing produces uncomfortable thirst, and one or two hours of violent 
exercise may do so at once. 

Continued deprivation of water causes the blood, by virtue of its 
self-regulating power, to withhold fluid from the kidneys and digest- 
ive glands. The digestive secretions therefore become less fluid, 
of more intense reaction, and greatly diminished in quantity. The 
mucous surfaces become dry, and the dryness, owing to the passage 
of air and the consequent evaporation, is first felt in the mouth and 
pharynx. The diminution in the digestive secretions, as well as their 
altered strength, interferes with or retards their normal action upon 
the ingesta. The proper movement of the food in the stomach and 
intestines is retarded by its greater solidity and by the increased 
friction of the mucous walls, especially in the lower bowel. Consti- 
pation therefore results. The absorption of fluid through the walls 
of the alimentary canal is retarded, and nutrition suffers in conse- 
quence. Meanwhile the blood, to maintain its normal character, re- 
absorbs water from the lymph spaces and different tissues of the 
body. The muscles and other structures become dry and diminish 
in volume. Emaciation results, which quickly reaches an extraordi- 
nary and painful degree. The mind dwells on water constantly, and 
taste is diminished. Finally, the nervous system suffers from dry- 
ness and various nervous symptoms ensue, so that, in addition to 
extreme muscular weakness and prostration, there may be convul- 
sions, delirium, and finally coma and death. 

Thirst. — As far as the individual is concerned, the suffering from 
deprivation of water is mainly confined to the sensations of thirst 
and dryness of the mouth. Thirst is commonly, and somewhat er- 
roneously, referred to the mouth and the pharynx. It is true that 
the mucous membrane in these regions becomes dry when water is 
withheld, but thirst may be also keen when these surfaces are abun- 
dantly moist. The sensation is the result chiefly of the expression 
through the nervous system of the need of the body tissues in gen- 
eral for fluid, and it is referred to the mouth and throat from force 
of habit, which associates the act of swallowing fluid, and the use of 
certain muscles in that process, with the subsequent relief of thirst. 
In support of the above statement is a fact that I have several times 
witnessed in patients having a gastric fistula made in consequence of 
oesophageal stenosis, or in patients nourished wholly through nu- 
trient enemata, that the sensation of thirst referred bv them to the 



44 FOODS AND FOOD PREPARATIONS 

mouth is immediately relieved by the injection of water into the 
stomach through the fistula, or of salt and water into the rectum. 

It is asserted that shipwrecked sailors in open boats have relieved 
their thirst by immersing their bodies in salt water. A very little 
water is possibly absorbed under these conditions through the skin. 
Ordinarily, however, the skin is not capable of absorbing fluid of 
any kind to a practical extent, but immersion in water prevents 
evaporation from the surface of the body, and by saving its loss in 
that direction lessens thirst. Sucking a slice of lemon or drinking 
water acidulated with a few drops of lemon juice or vinegar some- 
times allays thirst better than plain water. The same may be said 
of barley and oatmeal waters. Lime juice and ice is another remedy. 
Bitartrate of potassium or very weak brandy may be used for the 
same purpose, and is sometimes more satisfying. 

On one of the arctic expeditions which resulted disastrously 
the men had no water for two months, but ate snow, having no fuel 
to spare to melt it. 

" Hot water, as hot as can be sipped, quenches thirst much better 
than cold " (Balfour). 

Glycerin and water is sometimes used to allay thirst by rinsing the 
mouth. The glycerin, being viscid, coats the surface of the mucous 
membrane and prevents to some extent the drying by evaporation, 
but it is hygroscopic and tends to abstract water if used too strong, 
and practically it is of little service. 

When it is undesirable to give water by the mouth, thirst may be 
relieved by injection of salt and water beneath the skin (see Hypo- 
dermoclysis) or into the rectum. 

Thirst may be controlled somewhat when it is desirable to re- 
strict the fluids ingested by giving small doses of opium (Riegel). 
It may be that part of the benefit derived from this dru^^in the 
treatment of diabetes is due to its controlling this symptom. It is 
taken sometimes by professional fasters, who aim to abstain from all 
food, and from as much drink as possible. The latter is done be- 
cause without food water tends to promote tissue waste too rapidly, 
and loss of strength would be more rapid upon no food and an ex- 
cess of water than upon no food with water in great moderation. 

Temperature of Drinking Water. — Water is drunk at various tem- 
peratures from that of melting ice to no or 112 F. It is some- 
times stated that the temperature of water influences digestion, but 
the extent to which it does so is much exaggerated. Very cold water 
swallowed quickly in large amount is said to contract the stomach 
wall and stimulate the heart action. Lehman says that water drunk 
at 6o° F. causes a fall in the pulse rate and in rectal temperature, but 
these observations lack confirmation. This subject, as well as that 
of the local action of hot water, will be found more fully discussed 
under the heading Temperature and Digestion. 



SALTS 45 

Ice is often useful in the sick-room, but it should not be given to 
young infants. Cracked ice sometimes soothes an inflamed throat, 
and occasionally it allays nausea. It relieves thirst only temporarily, 
and this symptom may be increased by its prolonged use. If too 
much is swallowed it becomes lukewarm in the stomach and may be 
vomited. 

II. SALTS 

Varieties of Salts. — The principal salts derived from the food 
are as follows : 

Chlorides of sodium and potassium ; carbonates of sodium, potas- 
sium and magnesium ; sulphates of sodium, potassium and magne- 
sium ; phosphates of sodium, potassium, magnesium, and calcium. 
The majority of these salts are held to be unaltered by digestive pro- 
cesses and pass into the blood or tissues without necessary chemical 
change. The reason for this belief is the fact of the readiness with 
which they can be obtained, unaltered by chemical analysis, from the 
different tissues of the body and the urine. Some compounds — 
namely, the salts of iron and salts of the organic acids — are ingested 
in very minute quantity and their uses are but vaguely understood. 
Other salts, such as the chlorides, carbonates, and phosphates of the 
alkalies and alkaline earths, are taken in much larger daily amount 
and subserve definite purposes. 

Uses of Salts in Food. — The uses of the salts derived from the food 
are summarised as follows : 

I. To regulate the specific gravity of the blood and other fluids 
of the body. 

II. To regulate the chemical reaction of the blood and the various 
secretions and excretions. 

III. To preserve the tissues from disorganisation and putre- 
faction. 

IV. To control the rate of absorption by osmosis. 

V. To enter into the permanent composition of certain structures, 
especially the bones and teeth. 

VI. To enable the blood to hold certain materials in solution. 

VII. To serve special purposes, such, for example, as the influ- 
ence of sodium chloride on hydrochloric-acid formation, and that of 
lime salts in favouring coagulation of the blood. 

Generally speaking, fruits and nuts contain the least quantity of 
salts, meats rank next, after them vegetables, and pulses and cereals 
contain most of all. 

Excess of Salt. — Salts of any kind when taken in excess with 
the food disagree with digestion in various ways. They may prove 
locally irritant to the gastric or intestinal mucous membrane; they 
modify the rate of absorption of digestive material, and alter the 
intensity of reaction of the different digestive fluids. After being 



46 FOODS AND FOOD PREPARATIONS 

absorbed in excess they may interfere with the nutritive and chem- 
ical processes of the blood and tissues. Some persons acquire a salt- 
eating habit and partake too freely of common salt with the food, 
with the result of the production of more or less dyspepsia or 
some of the symptoms above mentioned. Too much salt in the 
food produces thirst, and may even stimulate a craving for strong 
drink. 

Lime salts and phosphates when taken in food or drinking water 
in large quantities for several weeks or months tend to cause the 
deposit of renal or vesical calculi. 

Deprivation of Salt. — Continued deprivation of any one of the 
common salts, so long as others are furnished in reasonable abun- 
dance in the food, does not result seriously. If, however, all the salts 
are reduced in quantity, of if they are entirely excluded from the 
diet, the system very soon begins to evince signs of malnutrition. 
This is readily accounted for by referring to the uses of salts above 
described. Animals or men deprived of salts for a long time suffer 
greatly from indigestion and from lack of bodily nutrition. The 
body may not diminish in weight, but the tissues become " flabby," 
the muscles feeble, the mind stupid and dull, the nutrition of the skin 
is altered, it becomes dry, and there is falling out of the hair. Event- 
ually, in animals with salt starvation death occurs in from six to eight 
weeks from progressive bodily weakness and inanition — a condition, 
practically, of marasmus. 

Young infants who do not obtain sufficient salts of lime — i. e., if 
fed upon proprietary " infant foods " instead of good milk — become 
rhachitic ; their bones ossify slowly and bend into deformities. Such 
children are sometimes given hypophosphite-of-lime biscuits to sup- 
ply the deficiency, but they should be properly fed upon fresh milk. 
(See Rhachitis.) 

Sodium Chloride. — Sodium chloride, or common table salt, is by 
far the most important and valuable salt, and is used in the largest 
amount. It has long been a symbol of wisdom and hospitality in 
the East. It forms 60 per cent of the salts of the blood, and enters 
into the structural formation of all the tissues and secretions of the 
body in greater or less quantity, with the single exception of the 
enamel of the teeth. It is estimated that the quantity which may be 
daily appropriated from the food is about fifteen grammes. Salt 
slightly stimulates the renal secretion, which in turn leads to thirst 
and to drinking more fluid, which promotes interchange of the juices 
of the body. It also excites thirst more directly. 

Common salt stimulates the appetite and influences beneficially 
the gastric secretion. It not only furnishes the chlorine for hydro- 
chloric acid, but seems to act locally in the stomach by promoting 
this secretion as well as the conversion of pepsinogen into active 
pepsin. Cohn and Voit have proved that the absence of salt from 



SALTS 47 

the diet completely checks the production of hydrochloric acid in the 
stomach. 

There are some few tribes of flesh-eating men who do not add 
salt to their food, relying for their needs upon what they derive 
from the food itself. This supply is therefore sufficient to maintain 
life. In fact, as a rule, man derives enough salts from the compo- 
sition of his food to supply the tissues and juices of the body, and 
the additional quantity which he takes as table salt is mainly of serv- 
ice as a condiment, to give agreeable flavour to a mixed diet and to 
sharpen the appetite. The excess of salts in general is promptly 
eliminated in the urine. 

In most men and many of the higher mammalia the craving for 
sodium chloride is instinctive. Stanley records in his book " In 
Darkest Africa " instances where savages are accustomed to travel 
many hundreds of miles under great difficulties to obtain a coveted 
supply of salt. 

Herbivorous animals are even more dependent upon salt than are 
carnivores ; cattle and sheep, for example, must be given salt in ad- 
dition to that contained in their food to remain in good condition. 

Overdoses of salt cause diarrhoea and even gastro-enteritis, and 
excite irritation of the nerves of the throat. 

Large doses of salt have been given in pleurisy with the view of 
increasing the density of the blood and causing reabsorption of the 
pleuritic fluid by promoting osmosis towards the vessels. This treat- 
ment has not met with success. The popular use of salt to control 
pulmonary haemorrhage is of no practical value. 

Almost all vegetables contain less sodium chloride than does milk, 
the food of the young growing animal, although many of them have 
more potassium. 

Sodium chloride is of great service as a preservative of foods, 
either used as a brine in pickling, corning beef, preserving olives, etc., 
or in solid form to dry and keep meat and fish from decomposition. 

Potassium Salts. — Next in importance to sodium chloride ranks 
potassium chloride, which is the predominant salt of the muscles, and 
which, like sodium chloride, is a common ingredient of nearly all the 
tissues and fluids. The acid and neutral carbonates and phosphates 
of sodium and potassium are important in regulating the reaction 
of the digestive secretions and the urine. 

Calcium. — The salts of calcium are chiefly of value from their 
constituting a large percentage of the composition of the bones and 
teeth, as well as a smaller percentage of many other tissues of the 
body. Their presence seems to be associated constantly with cell 
growth and development. The carbonate is often found with the 
phosphate of lime, but in less quantity. The occurrence of cretinism 
and goitre has been in part attributed to an excess of lime salts in the 
food, more especially the drinking water; but this theory is not to be 



48 FOODS AND FOOD PREPARATIONS 

accepted without question. These diseases often occur indepen- 
dently of such cause, and are by no means always prevalent in lime- 
water areas. 

Young growing animals contain a larger percentage of earthy 
salts than do older ones. Deposits of salts of lime occur in old 
abscesses, tubercular concretions, tartar on the teeth, atheromatous 
blood vessels, the arcus senilis of the cornea, and as calculi. 

Phosphorus.— Phosphorus is derived from phosphates in meat 
and its contained blood which is eaten, as well as from vegetables. 
It enters into the composition of the bones, muscles, blood, etc. 

Sulphur. — Sulphur is derived from sulphates contained princi- 
pally in fibrin, egg albumen, the casein of milk, and from such vege- 
tables as corn, turnips, cauliflower, and asparagus. 

Iron. — The iron of the body is found in the blood pigment, where 
it amounts, all told, to a third of an ounce. It is also present in 
minute traces in other pigments. 

Its chief source is from the blood of animals which is cooked with 
their meat. Two quarts of milk furnish about one eleventh grain of 
iron. It is also derived from, and it may be taken with, chalybeate 
waters. Probably most of the iron of the body is retained and used 
again and again. The daily quantity of iron ingested with an ordi- 
nary mixed diet is about one eighth grain. 

Vegetable Acids 

The common organic or vegetable acids — citric, tartaric, malic, 
etc. — are derived from fresh vegetables and fruits, in which they exist 
usually in combination with the bases Ca, Na, K, etc. They are 
indispensable articles of food, for when absorbed they form carbon- 
ates, which aid in maintaining the alkalinity of the blood. Prolonged 
deprivation of them usually results in the condition of scurvy. 

III. ANIMAL FOODS 

Animal foods contain much nutritive matter in a more or less 
concentrated form which exists in practically the same chemical 
combination with the body itself. They leave comparatively little 
residue, being quite thoroughly digested. They are agreeable in 
flavour, and they hold salts, including iron, which are of special value 
as force producers. They are, however, inferior to starches in this 
property unless much fat be incorporated with them. 

The varieties of animal foods will be described under the head- 
ings, milk, eggs, meat, fish, gelatin, fats. 

Milk 

The milk of several animals, such as cows, goats, asses, mares, 
and camels, may be used for food, but in this country very little other 



ANIMAL FOODS 49 

than cows' milk is employed. The varieties of milk differ slightly in 
chemical composition, odour, and taste, but they all contain the ele- 
ments which are necessary for the maintenance of life in fairly eco- 
nomical proportion, so that for infants they constitute a " complete " 
food which fully meets the requirements of the growing body, and in 
adults they will sustain life comfortably for many months. 

For these reasons milk ranks among the most important of all 
foods, and it is necessary to determine to what extent it should be in- 
troduced into ordinary diet. A pint of milk may be said to represent 
approximately the nutrition contained in six ounces of beef or mut- 
ton. Although it furnishes so useful a food, milk is by no means 
essential to a diet designed for increasing bodily strength, and it is 
usually omitted from the menu of athletes in active training. 

Milk taken alone constitutes an insufficient diet for adults in 
health, for to obtain the requisite 18.3 grammes of nitrogen 2,905 
grammes of milk only are needed, against 4,652 which must be taken 
to obtain the necessary 328.9 grammes of carbon (Bauer). (See 
Force Production, page 20.) 

Adults who are able to eat any kind of food usually maintain their 
health in better condition by abstaining from milk except as used for 
cooking purposes, inasmuch as it makes many persons " bilious " to 
drink it, and produces constipation, particularly when taken in excess 
with other foods. 

Sir Henry Thompson, in condemning the excessive drinking of 
milk by persons in good health who are at the same time eating large 
meals of meat, says : " It is altogether superfluous and mostly mis- 
chievous as a drink for those who have reached adult age and can 
digest solid food." There are, however, many diseases in which a 
partial, or for a time an exclusive, milk diet is to be recommended. 

Milk in considerable quantity — i. e., equal to one third or one half 
the total amount of food consumed — is often highly desirable in such 
diseases as tuberculosis, chronic Bright's disease, and anaemia. 

Exclusive Milk Diet. — An exclusive milk diet is useful in the 
following conditions and diseases : 

1. In infancy for the first year, and sometimes for the first 
eighteen months. 

2. All acute infectious diseases of young children. 

3. Typhoid fever. 

4. Acute Bright's disease, and at times in chronic nephritis. 

5. Acute pyelitis. 

6. Chronic gastric catarrh. 

7. Gastric ulcer and carcinoma. 

8. Neurasthenia. 

A milk diet is so easy to prescribe, so cheap, and so easily pro- 
curable, that it is always the first resort of those who, from indiffer- 
ence or lack of knowledge of the first principles of dietetics, are 



50 FOODS AND FOOD PREPARATIONS 

unwilling or unable to take pains to study the peculiarities and 
needs of the individual case. It is an easily measured food, and it 
becomes a routine practice in hospitals — where almost always more 
attention is awarded to medication than to diet — to order milk diet 
for all patients who are not at the convalescent or full house table, 
and it is doubtless safe to err in this direction, but it is by no means 
always the best that can be done for the patients. 

An exclusive milk diet in time becomes monotonous and weari- 
some to most adults, and may produce dyspepsia, constipation, and 
interfere with the functional activity of the liver. Aside from nausea, 
which the continued use of milk may excite, a positive loathing for 
the taste of it may be developed, unless the regimen is modified 
by occasional variation. This is a matter of considerable impor- 
tance in feeding patients suffering from typhoid fever, chronic 
Bright's disease, chronic gastric catarrh, and other affections for 
which milk diet is often prescribed ; for if other substances are sub- 
stituted from time to time in small amounts, while milk is still re- 
tained as the chief food, it may be continued as such for a much 
longer time. On seeking the cause for the disagreement of milk, it 
is found in the fact that it contains too large a proportion of nitro- 
genous material as compared with the hydrocarbons, so that, in order 
to obtain sufficient of the latter, an excess of proteid is ingested, 
which interferes with normal digestion. 

For a man in health a pure milk diet, as Ewald says, is " slow 
starvation," although it is an excellent food for a short time. If kept 
too long upon it, he develops a condition akin to scurvy. (See 
Diet in Scurvy.) This, however, does not invariably follow in 
disease, and J. K. Mitchell refers to a patient with diabetes and 
nephritis who lived upon milk alone for seven years, and kept in 
active business. 

Infants and children tire of milk less easily than adults. Whereas 
the adult needs twenty-three ounces of water-free food per diem to 
maintain healthful equilibrium, he must consume nine pints of milk 
at a specific gravity of 1.030 to supply it. The excess of albumin, 
fat, and water which he would then obtain is wasteful for him, 
although it is good for the young. But in illness life is comfortably 
maintained upon a smaller quantity for a few weeks, and in typhoid 
fever four or five pints is an ample allowance, and it is often better 
to give less. (See Diet in Typhoid Fever.) In a case of chronic 
Bright's disease, if the patient is not confined to bed, it may be neces- 
sary to give six or seven pints. 

In order to digest large quantities of milk it must be taken in 
measured doses at frequent intervals. In typhoid fever, for ex- 
ample, from three to five ounces may be given every two hours. In 
some diseases it is best to give two ounces every hour, in others six 
or eight ounces everv three hours. 



ANIMAL FOODS 5 I 

Milk leaves no coarse waste residue in the intestine like the indi- 
gestible fibre of meat or the cellulose of vegetables and fruits. Not- 
withstanding this fact, an exclusive milk diet yields considerable bulk 
of fecal matter, and a typhoid-fever patient living on milk alone often 
has daily evacuations of medium size. Riibner found that in health a 
diet of milk alone yields larger stools than either roast beef or Qgg 
alone. Yet by weight the absorption of milk is shown to be very 
complete, and four thousand grammes of milk ingested by the mouth, 
when perfectly digested, yield but one hundred grammes of feces 
(Riibner). There is a marked loss through the feces of the salts of 
lime which have been contained in the milk. These facts explain 
in part why milk is so constipating. 

Prof. Charles E. Wait, in the course of nutrition investigations 
of a club of students at the University of Tennessee (U. S. Depart- 
ment of Agriculture, Bulletin No. 53, 1898), says: 

" The average of ten experiments with an exclusive milk diet 
showed 92.1 per cent of the protein and 86.3 per cent of the carbo- 
hydrates to be digested. Five experiments made with an exclusive 
bread diet or with bread and sugar showed 82 per cent of the protein 
and 99 per cent of the carbohydrates to be digested. Five experi- 
ments with a diet of bread and milk showed 97.1 per cent of the 
protein and 98.7 per cent of the carbohydrates to be digested. In 
other words, the protein in milk alone or in bread alone seems to 
be much less completely digested than when the two are eaten 
together." 

" Milk Cure." — The " milk cure " has been carried out success- 
fully by Pecholier, Weir Mitchell, Karell, and others for the treat- 
ment of obstinate hysteria, hepatic congestion, dropsy, and various 
anomalies of nutrition. The patient is given no food but milk, 
which Pecholier orders every two hours in small amount, increasing 
the quantity until three litres a day are taken. Mitchell commences 
with doses of half an ounce to two ounces every two or three hours, 
and increases the dosage by half an ounce until sixty ounces or 
more are taken. If the taste of milk is disagreeable, coffee, salt, or 
caramel is added. If thirst is complained of, natural water or Seltzer 
water is given. After three or four weeks, rice, arrowroot, and thin 
slices of white bread are allowed, and after five weeks raw meat or 
one or two cutlets. The milk, meanwhile, is continued. After a 
day or two of this treatment, hunger and thirst are not usually com- 
plained of. At first the pulse is accelerated, but there is seldom any 
conspicuous nervousness. The tongue is coated, the water in the 
urine is increased, there is obstinate constipation (which must be 
relieved by enemata or medicines), the stools are hard and ochre or 
white in colour, and a great deal of epigastric distress and feeling of 
emptiness are present. The arterial tension is lowered ; there may be 
muscular prostration. There is loss of weight at first. If the treat- 



52 



FOODS AND FOOD PREPARATIONS 



ment is persevered in, at the end of a fortnight there is marked 
improvement in the feelings and condition of the patient, and after 
six or eight weeks the cure is usually far advanced. 

Chemical Composition of Milk. — The chemical ingredients which 
make milk valuable as a food are water, salts, fats, milk sugar or 
lactose, and albuminous materials, chiefly casein, with some albumin. 
Scheibe and Henkel claim to have found traces of citric acid in nor- 
mal cow's milk. 

The published analyses of milk vary slightly, chiefly in regard to 
the quantity of fats observed. 

The following analyses are placed together for comparison : 





Wanklyn. 


London Dairy. 


Bell. 


Leeds. 


E. W. Stewart. 


Fat 


3.20 

9-3o 


4.IO 

8.80 


4.OI 

9-3i 


3-75 

8.86 


3.80 
9.20 


Other solids 


Total solids 

Water 


12.50 

87.50 


12.90 
87.IO 


13-32 

86.68 


12.61 
87-39 


I3.OO 
87.OO 






100.00 


IOO.OO 


100 . 00 


100 . 00 


IOO.OO 



The above London Dairy analysis is based upon the examination 
of 120,000 samples of milk conducted by the chemist to the dairy 
during a period of twelve years. The third analysis is by Dr. J. 
Carter Bell, an English public analyst, and the fourth is by Prof. 
Albert H. Leeds. 

Fat and Cream. — Milk fat is mainly formed of glycerides of 
palmitic and oleic acid (Warington), the latter constituting about 
50 per cent (Ruppel), with five or six other fatty acids, such as 
myristic and stearic, represented in minute quantity. 

While the percentage of fat in milk, as shown by chemical anal- 
ysis in the above tables, is about 4 per cent, that of cream itself is 
considerably higher, but cream is not pure fat. It is simply an aggre- 
gation of the oil globules in the top portion of the milk with a little 
proteid and carbohydrate. Average milk contains 8 to 10 per cent 
of cream. Alderney milk may have as high as 20 or even 30 per 
cent. Good milk should form a layer of cream about two inches 
and a half thick as it stands in a quart bottle. 

The globules of milk fat vary in size between 0.0005 an d 0.00005 
inch in diameter, and the smallest do not rise to the surface as cream, 
for their albuminous coverings are proportionately heavier (Waring- 
ton). " The fuel value of a pint of cream is not far from 1,425 calo- 
ries, or about the same as one and one eighth pounds of bread, or 
one and one half dozen bananas, or four and one half pounds of pota- 
toes " (A. C. True). 

The following table is from the U. S. Department of Agriculture, 
Farmers' Bulletin No. 74, 1898: 



ANIMAL FOODS 



53 



Amounts of Nutrients in a Pound {Pint) of Milk as compared with a 
Pound of Meat, Bread, and Other Food Products 



Food Materials. 



Milk (i pint). 

Whole milk 

Skim milk (0.3 per cent fat) 
Buttermilk 

Other food materials 
(1 pound each). 

Cheese 

Butter 

Beef, sirloin 

Mutton, side , 

Pork: 

Loin 

Ham 

Salt, fat 

Chicken 

Codfish : 

Fresh 

Salt 

Mackerel, salt 

Oysters, solids 

Wheat flour ,-. 

Cornmeal 

Oatmeal 

Wheat bread 

Crackers 

Dried beans 

Beets 

Potatoes 

Turnips 

Apples 







EDIBLE PORTION. 




Water. 


NUTRIENTS. 


Protein. 


Fat. 


Carbo- 
hydrates. 


Mineral 
matter. 


Pound. 


Pound. 


Pound. 


Pound. 


Pound. 


O.87 


O.O3 


O.O4 


O.O5 


O.OI 


O.9O 


O.O4 




O.05 


O.OI 


O.gi 


O.O3 


O.OI 


O.O5 


O.OI 


O.34 


O.26 


0.34 


0.02 


0.04 


O.II 


O.OI 


O.85 




0.03 


0.53 


O.I6 


O.I7 




O.OI 


0.43 


O. 13 


O.24 




O.OI 


O.44 


O.I4 


0.25 




O.OI 


0.35 


O.13 


0.34 




0.04 


O.07 


0.02 


O.87 




0.04 


O.48 


O.I5 


O.OI 




O.OI 


O.58 


O.II 






O.OI 


O.4O 


0.16 




.... 


0.19 


O.38 


0.17 


0.17 




O.IO 


O.88 


0.06 


0.02 


O.O3 


O.OI 


O.I2 


O.II 


O.OI 


0.75 


O.OI 


O.I3 


0.09 


0.02 


0-75 


O.OI 


O.O7 


0.16 


0.07 


O.68 


0.02 


0.35 


O.IO 


O.OI 


0.53 


O.OI 


O.08 


O.II 


O.IO 


O.69 


0.02 


O.I3 


0.22 


0.02 


0.59 


0.04 


O.70 


O.OI 




O.08 


O.OI 


O.67 


0.02 




O.I5 


O.OI 


O.62 


O.OI 




O.06 


O.OI 


O.62 


O.OI 




O.I2 





Fuel 
value. 



Calories. 



325 
I70 
I6 5 



1,05 
3,605 
1,040 
1,275 

1,340 

1,655 

3,715 

325 

205 

315 
1,050 

235 
1,645 
1,655 
I,86o 
1,205 
1,895 
1,590 

170 

325 
135 

255 



Solids Other than Fat. — These are as follows : 





Wanklyn. 


Leeds. 


E. W. Stewart. 


Ash 


O.60 
4.40 
4-30 


O.68 
4.42 
3.76 


O.60 


Lactose 


4-55 
4-05 


Albuminoids 



Letheby gives the percentage of lactose as 5.2, which is too high 
for the average. 

Lactose. — Lactose is an important ingredient of milk. When 
chemically pure it is hard, transparent, white, and crystalline. It is 
now obtainable in much purer commercial form than formerly, when 
in addition to its diuretic effect, if given therapeutically, it often ex- 
cited fermentation and even glycosuria. It has but a faintly sweetish 
taste, and in its properties is allied to both sucrose and starch. Its 



54 FOODS AND FOOD PREPARATIONS 

chief function in human milk is to supply energy for heat produc- 
tion for the infant whose muscles are not yet active in developing 
this force, and it constitutes about one half of the total solids of milk, 
exclusive of fat ; but the quantity present in cow's milk varies greatly, 
and, as a general rule, it bears an inverse ratio to the amount of fat 
and casein present. It is less liable than cane sugar to ferment in 
the stomach ; and alone it is not susceptible to alcoholic fermentation, 
but in the presence of fermenting nitrogenous material it is con- 
verted into lactic acid, making the milk sour. It is promptly ab- 
sorbed from the alimentary canal, not remaining over an hour in the 
stomach. 

Casein and Albumin. — The principal albuminoid of milk is casein, 
but there are a half dozen proteids which have been described, show- 
ing different behaviour on coagulation, in polariscopic rotation, etc. 
There is an albumin present called lactalbumin, which is coagulable 
by heat and forms the tenacious " scum " which floats on top of 
boiled milk. This albumin plays an important role by surrounding 
the minute oil globules of the milk and preventing them from agglu- 
tination — in other words, it helps maintain the fat in permanent fine 
emulsion. It is contained in solution in whey. Traces of peptones 
have also been found in milk. 

Casein itself is non-coagulable by heat, even by boiling, but it is 
coagulated in firm tough clots by acids, such as the hydrochloric 
acid of the gastric juice, and by many organic acids which occur as 
products of malfermentation in the stomach. Lactic acid is the com- 
mon agent in forming the coagulae. Casein is also coagulated, but 
less firmly, by the special milk-curdling ferment " rennin," which is 
actively present in the infant stomach, and in the third stomach of 
the calf. The casein clot formed by rennin, unlike that of lactic acid, 
is not redissolved by neutralisation with alkalies. Casein is present 
in milk chiefly in an alkaline form as potassium caseinate, and in 
conjunction with calcium phosphate. 

Varieties of Milk. — Cow's milk differs much in quality accord- 
ing to the breed and condition of the animal, quality of its food, and 
care bestowed upon feeding and hygienic surroundings. The chief 
variation concerns the quantity of cream produced. 

The milk of Alderney, Jersey, and Guernsey cows has more pro- 
teid than that of ordinary animals, and Alderneys give more fat 
than longhorns. Individual cows are liable to vary among them- 
selves and from day to day in the quantity of their milk, and there- 
fore, notwithstanding general belief, it is a disadvantage to feed an 
infant always upon the milk of the same cow. More uniformity will, 
on the average, be secured by feeding the mixed milk of several ani- 
mals, the variations in the components neutralising each other. 

" Strippings " is the name given to residual milk which may be 
drawn off shortly after the ordinary milking has been completed. 



ANIMAL FOODS 55 

Contrary to popular belief, it possesses no advantage as food over the 
rest of the milk, and what little difference in composition exists can 
be artificially produced. It is richer in fat but poorer in casein than 
the milk first drawn. For infant use it should be diluted with two 
parts of water. 

Human Milk. — Human milk differs from cow's milk in several 
important particulars. For this reason it becomes necessary when 
infants are fed upon the latter to so modify it as to render it more 
digestible for them. 

The important differences between human milk and cow's milk 
are that woman's milk is sweeter by one third and contains little 
less than half as much casein. The analyses of the United States 
Department of Agriculture give the percentage of casein in cow's 
milk as varying between 3.43 and 3.91, whereas that of mother's milk- 
averages 1.5, hence the importance of diluting cow's milk in the early 
months of infant feeding. As Leeds says, the calf grows faster 
and has to manufacture more muscle than the baby — it needs more 
albumin for tissue building. The casein of mother's milk, moreover, 
forms smaller coagulae both with rennet and in the stomach, which 
are more easily dissolved. The normal reaction of human milk is 
alkaline. Cow's milk varies from faintly alkaline to neutral, and it 
often becomes acid, especially when the animals are not pasture-fed. 
There is nearly one half per cent more fat, and the globules exist in a 
finer emulsion in woman's than in cow's milk. Cow's milk appears 
richer, whiter, and more opaque than human milk. 

These differences are emphasised by the following comparative 
analyses by Leeds of average cow's milk and human milk : 





Sound dairy milk. 


Human milk. 


Reaction 


Feebly acid. 

1029.7 

Always present. 

3.75 per cent. 
4.42 

3.76 " 
0.68 


Persistently alkaline. 

1031-3 
Absent 


Specific gravity 


Bacteria 


Fats 

Lactose 


4.13 per cent. 

7.0 

2.0 


Albuminoids 


Ash 


0.2 " 






Total solids 


12.61 


13-33 





It requires more acid to precipitate the proteid from woman's 
milk than from cow's milk. Giving a nursing woman an excess 
of nitrogenous food does not increase the albuminoid elements of her 
milk so much as the fats, while giving fattv or rich food in excess 
does not increase the cream or other ingredients of her milk — it may, 
indeed, diminish them by disordering her digestion. The nursing 
mother's diet must therefore be plain but substantial, especially in 
regard to animal foods. Excessive fat or proteid in the milk dis- 
orders the infant's digestion. 



56 



FOODS AND FOOD PREPARATIONS 



The following analyses illustrate the extent of possible variation 
in good specimens of human milk : 

Eight Human Breast-milk Analyses (C. Harrington) 
(Infants all digesting well and gaining in weight.) 





I. 


II. 


III. 


IV. 


V. 


VI. 


VII. 


VIII. 


Fat 


Per cent. 

4-37 
6.30 

3-27 
0.16 


Per cent. 
3.76 

6-95 
2.04 
O. 14 

12 89 
87.II 

lOO.OO 


Per cent. 
3.16 
7.20 
I.65 
0.21 

12.22 

87.78 

lOO.OO 


Per cent. 
3.82 
5-70 
I.08 
0.20 


Per cent. 
2.96 
5.78 
1. 91 
O.I2 


Per cent. 
2.O9 
6.70 
I.38 
O.I5 


Per cent. 
2.02 

6-55 
2.12 

O.I5 

IO.84 
89.16 

lOO.OO 


Per cent. 
2.36 
7.IO 
2.20 
O.I6 


Milk sugar 

Albuminoids .... 
Mineral matter. . 


Total solids . . . 
Water 


14.10 

85.90 
100.00 


IO.80 
89.20 


IO.77 
89.23 


IO.32 
89.68 

lOO.OO 


11.82 
88.18 








lOO.OO 


lOO.OO 


lOO.OO 



For the analysis of human milk about half an ounce is required, 
drawn from the middle nursing period, for the milk becomes pro- 
gressively richer during nursing. 

Prof. Albert H. Leeds (American Text-book of the Diseases of 
Children, pp. 42, 43) has shown, by a table of analyses of milk from 
eighty women of different nationalities, ages, and periods of lactation, 
that although " the average amount of nitrogenous matters [albumi- 
noids] is somewhat greater at beginning of lactation, the difference 
is not very marked. . . . There is no progressive change in the 
composition of milk during lactation, but after the function has been 
normally established the milk remains substantially the same during 
the entire period. . . . The child obtains more nutriment day by 
day, but it is by spontaneously increasing the quantity according to 
the best rule, which is that of normal appetite, and not by absorbing 
stronger and stronger food." 

Somewhat different conclusions are reported by Vanderpoel 
Adriance and John S. Adriance, based upon analyses of the milk of 
120 healthy mothers at the Nursery and Childs' Hospital, New York. 
In each case the sample was obtained after allowing the infant to 
nurse for two minutes, and periods studied were from the second 
day to the fifteenth month of lactation. They found that of all the 
ingredients of human milk the fat varies most, and varies throughout 
lactation, the extremes being 7.61 and 1.31 per cent. The fat bears 
a rough general proportion to the proteid of 3 : 1. The carbohydrate, 
which weighs during the middle period of lactation more than all 
the other solids together, increases throughout lactation, and ranges 
from 5.35 to 7.95 per cent. 

The proteid percentage is highest during the colostrum period, 
when it may reach 8.60 per cent, and falls rapidly towards the end 
of lactation. Pfeiffer found it as low as 1.52 at the seventh month, 
but this is extreme reduction. It is increased by worry and nervous- 



ANIMAL FOODS 57 

ness and by lack of exercise ; it is lessened by reduction of meat in 
the dietary, and vice versa. The salts diminish from .27 per cent 
on the second day to .14 at the fifteenth month. 

The average specific gravity is given by Adriance as 1.030. It is 
lessened by increase of fat and increased by increase of proteid. 

Human colostrum differs from the later milk as follows : It con- 
tains colostrum corpuscles which remain from seven to ten days ; it 
has a yellow colour, which disappears with the corpuscles ; it is 
laxative to the infant ; its fat varies greatly ; the quantity of sugar is 
lowest and of proteid and ash highest of any period of lactation. 

Drugs in Human Milk. — Many drugs are excreted through the 
mother's milk, and it is often the case that an infant is affected by 
suckling such milk. It is possible to act upon infants through this 
medium, but the strength of solution in which the drug reaches them 
is far too uncertain. An infant has been killed by nursing from a 
mother who had taken an overdose of laudanum (Fletcher). Acids 
given to a nursing mother may cause colic in the child. Neutral 
salts loosen the bowels, and potassium salts act as diuretics for 
infants when taken by the mother. Aromatic oils, and probably all 
volatile oils, reappear in the mother's milk. The agreeable taste 
of some of these substances causes the child to suck harder, and 
excites thereby a reflex stimulation of the mammary glands to fur- 
ther secretion. 

Among other drugs which have been determined in the mother's 
milk after ingestion by the stomach are : Senna, rhubarb, scammony, 
sulphur, castor oil, ammonium salts, turpentine, copaiba, anise, dill, 
garlic, wormwood, and jalap. Antimony passes readily into mother's 
milk, and should be given with caution to nursing women. Potas- 
sium iodide, corrosive sublimate, and other mercurial salts, arsenic, 
zinc, and lead, all may be excreted in the milk at periods varying from 
four hours to several days after their administration and continue to 
be eliminated for a day or two after the drug has been withheld. 

Vegetable acids give rise to carbon dioxide in milk. If nursing 
mothers partake freely of fresh fruit and green vegetables their milk 
may gripe and purge their infants. Violent exercise and violent 
mental emotion are harmful to the milk. 

Goafs milk is the least digestible and nutritious of milks, although 
it contains the most solids. It is scarcely used at all in the United 
States except sometimes by very poor foreigners, as it is in Switzer- 
land and other mountainous European countries, and for some East- 
ern tribes it is a staple variety of milk. Cheese is also made from it 
on a large scale. It has a peculiar strong odour and taste, which are 
disagreeable to those who are unaccustomed to it, and which are par- 
tially expelled by boiling. They are due to a substance called hircin 
or hircic acid. 

Goat's milk contains an excess of fat, and for this reason is too 
6 



58 FOODS AND FOOD PREPARATIONS 

rich for infant food, and gives rise to vomiting and diarrhoea. The 
coagulas formed by it are very tough. 

Ass's milk contains the least solids of all the edible milks, except 
mare's milk, and is poor in casein and fat. It has a fair proportion 
of sugar, more than cow's milk but less than human milk. Ass's 
milk is sweet and easy of digestion, although it has a tendency to 
cause diarrhoea. 

Experiments in the feeding of children direct from asses were 
conducted in Paris in 1883 at the Hospice des Enfans Assistes. One 
ass sufficed to nourish three infants besides her own foal. The asses 
were kept near the ward and the infants were brought to them to 
nurse. Syphilitic infants belonging to a class in which death had 
been the invariable rule were thus nursed, and 70 per cent were saved. 
The experiment does not seem to have found favour elsewhere. 
Goats were first tried, but proved of no service for direct nursing. 

Mares milk, like ass's, contains less proteid and less fat, but more 
lactose than cow's milk. 

The casein of mare's milk is intermediate in digestibility between 
human and cow's milk. Both ass's and mare's milk are used in the 
steppes of Russia and in Siberia for the manufacture of koumiss. 
(See Koumiss.) 

Reindeer milk contains 18 per cent of solids, and, generally speak- 
ing, those domestic animals living farthest north have the most solids 
in their milk. 

Milk Analysis. — An accurate analysis of milk requires much 
skill and the equipment of a well-organised laboratory, but it is often 
important for physicians to be able to judge for themselves of the 
quality of food so universally prescribed by them, and it is there- 
fore deemed appropriate to describe some of the easier methods of 
qualitative examination. The minimum standard to which milk 
must conform, as established by the New York City Health Board, 
is as follows : 

Per cent. 

Water 88 .00 

Fat 3.50 

Total solids 12.00 

Solids not fat 8 . 50 

Reaction, Colour, Taste, Odour. — Good cow's milk should be 
almost neutral, reddening blue litmus paper but very slightly if any. 
The normal colour is white and is due to the fat globules, but it may 
be slightly yellow, especially if the cow has been feeding in wheat 
fields (Hind). The taste is sweet and the odour faint and fresh. 
Bad milk often has a bad odour, either sour or derived from absorp- 
tion from some neighbouring material. It is sour to the taste, 
reddens litmus paper strongly, and if held to the light in a test tube 
or small thin glass it may have a bluish or reddish tinge and appear 






ANIMAL FOODS 59 

watery. It curdles in tough, stringy, or glutinous yellowish lumps 
of large size. 

Estimation of Total Solids. — To estimate the total solids of milk 
several tests are employed. Their object is to furnish data in regard 
to the nutrient power of the milk and to detect adulteration. 

A common method used by health boards is to weigh and evap- 
orate five cubic centimetres of milk to dryness in a small, flat-bot- 
tomed, platinum crucible of a known weight. This process takes 
about an hour. The residue is then dried for an hour more at ioo° 
F. and weighed. The milk dries in two layers. The upper layer 
consists of a thin film of fat, which is dissolved in petroleum and 
benzine. The lower honeycombed layer is then washed and dried 
and weighed again. The loss in weight after removing the upper 
layer represents the amount of fat present. The soluble salts and 
soluble proteid are then dissolved out by warm water and alcohol 
and separated. Ignition over a Bunsen burner drives off all organic 
matter, and leaves the ash, which is again weighed. 

Another less laborious method consists in the use of an instru- 
ment called a " lactometer," by which the specific gravity of the 
milk is taken. 

A lactometer is a glass spindle resembling a urinometer, but is 
about fifteen centimetres long, and it easily floats in a quart measure. 
It is graduated to measure the specific gravity from o° (the water 
line) to 40 . Milk in which it floats at below 29 is almost surely 
watered, or if it floats above 33 the milk is skimmed. The specific 
gravity of the milk being taken with the lactometer, the amount of 
dilution is readily computed by comparing it with the normal stand- 
ard, 30 . Suppose this specific gravity to be 21 in a given case, 
then 30:21:: 100:70. That is, the normal gravity, 30, is to the 
gravity of the sample examined as 100 parts of normal milk are to 
the sample, or, in other words, only 70 parts per hundred of the 
sample are milk, and 30 parts of water have been added. To facili- 
tate the calculation, the space between o° and 40 may be divided into 
100 parts; each division of the second scale represents i° or 1 per 
cent of milk. Thus, if the lactometer stands at 50 of this second 
scale, there is only 50 per cent of milk in the sample. 

There has been much dispute regarding the use of the lactom- 
eter, on the ground that an excessive amount of cream, on account 
of the lightness of the fat, diminishes the specific gravity of a really 
rich milk. On the other hand, it is claimed that the diminished 
gravity is always due to increase in the quantity of water, and that 
milk rich in cream will also contain less water, and therefore main- 
tain the normal standard. The matter has been tested in the courts, 
and in New York city the lactometer test alone is always sufficient 
to insure conviction in trials for adulteration of milk with water. 

Sometimes in estimating the specific gravity acetic acid is first 



6o 



FOODS AND FOOD PREPARATIONS 



added to precipitate the casein, which is removed with the fat ; the 
specific gravity of the whey is then taken. Hassell claims that the 
latter is more constant that the specific gravity of milk itself. 

L. Emmet Holt furnishes the following table of variations in 
specific gravity of human milk and their causes, as determined by a 
lactometer of his own device : 

Human Milk (Holt) 



Normal average 

Healthy variations.. . 
Healthy variations. . . 
Unhealthy variations 

Variations 

Variations , 

Variations 

Variations , 

Variations 



Specific gravity 
70 F. 



Cream — 24 hours. 



I. 031 

1.028 to 1.029. 
1.032 to 1.033. 
Below 1.028.. . 

Below 1.028.. . 
Below 1.028.. . 

Above 1.033. . 

Above 1.033.. 
Above 1.033. ■ 



Proteids. 



8 per cent 1.5 per cent. 

9 to 12 per cent Normal (rich milk). 

5 to 6 per cent Normal (fair milk). 

High (above 10 per cent). Normal or slightly 

below. 
Low. 

Very low (very poor 
milk). 

High Very high (very rich 

milk). 

Normal High. 

Low Normal (or nearly 

so). 



Normal (5 to 10 per cent). 
Low (below 5 per cent). . 



" Milk presenting only moderate variations from the average — 
e. g., specific gravity 1.028, cream 4 per cent, or specific gravity 
1.033, cream 10 per cent — can usually be modified by appropriate 
treatment. If, however, the specific gravity is from 1.018 to 1.024, 
and cream only 2 per cent to 3 per cent, it is hopeless." (Holt.) 

Estimation of the Fat. — To estimate the amount of fat or cream 
the sample of milk is allowed to stand in a cool place for twenty- 
four hours in a " creamometer." This is a simple glass tube twenty- 
five millimetres wide and twenty-five centimetres deep, which is 
graduated in hundredths from above downward. It is filled with 
milk to the zero level. The cream rises to the top, and the per- 
centage of volume is read off. 

This method is amplified by Marchand's process, in which a simi- 
lar graduated tube is employed, but the cream is more completely 
separated by means of the addition of ether and a little liquor sodse. 
Ninety-five per cent alcohol is then put into a flask with the milk, 
and the whole is vigorously shaken, after which it is allowed to stand 
at 130 to 140 F. In half an hour the fat forms a distinct layer at 
the top of the graduated tube. The error by this process is said to 
be less than 0.3 per cent. 

Dilution of milk by water is determined in the New York Health 
Board by use of a Swedish separating machine, the principle of which 
is as follows : Glass tubes are used having a diameter of about half 
an inch with a contracted neck graduated in percentages. A minute 
perforation at the neck admits the entrance of water. The tubes are 



ANIMAL FOODS 6 1 

first nearly filled with sulphuric acid and a measured quantity of 
milk is added. The tubes are corked with rubber, placed in a pan 
filled with water at 150 F., and rotated in a centrifugal machine at a 
speed of 40,000 revolutions a minute. The temperature of the 
water is then reduced to 52 F., and the percentage of fat is read 
off from the narrow neck of the tubes. Water is found to have 
entered through the perforation, and by its intermediate specific 
gravity it lies between and separates the fat and sulphuric acid. The 
process requires half an hour's time, and twenty samples may be 
examined at once. 

The richness of the milk in cream, or its dilution with water, may 
also be measured by its opacity. Five cubic centimetres of water 
are placed in a glass cell, called a " lactoscope " or " diaphanometer " 
(Dome), with parallel sides, through which a candle placed at a dis- 
tance of a metre may be seen. More milk is then added, drop by 
drop, until the opacity of the cell contents obscures the light. This 
method is more tedious and less accurate than the previous one. 
Cream varies in specific gravity between 1.010 and 1.024. 

A simple method of roughly determining the quantity of fat in 
human milk is given by Nias. The milk is placed in a test tube, 
made distinctly alkaline by a few drops of liquor potassse, boiled, 
and left for a few hours in a warm place. The fat, floating on the 
surface, is then estimated by graduations on the side of the test tube. 
It is of course necessary to use test tubes of uniform calibre in 
making comparative tests. 

Estimation of Lactose. — The method of quantitative estimation of 
milk sugar is the same as that employed for glucose in the urine. 
The casein is first precipitated by acetic acid. The whey is filtered 
and tested with Fehling's copper solution or with a polariscope. 
Convenient tables are made to facilitate the calculation. 

Estimation of Albuminoids. — In the method of Nias to determine 
the albuminoids the sample of milk is placed in a graduated test 
tube, as if to estimate the cream, and after some hours the super- 
natant fat is drawn off by a pipette. Acetic acid is next added until 
a strongly acid reaction develops. The milk is then boiled. All 
the albuminoids are precipitated, and after standing overnight the 
quantity may be read off on the side of the graduated tube. 

MILK ADULTERATION AND IMPURITIES 

Of recent years it has been discovered that a very large propor- 
tion of infant mortality is traceable to the use of impure milk, and 
that many diseases, especially diarrhceal disorders of summer, are 
preventable when proper care is exercised to protect the milk supply. 
The subject is rapidly claiming public attention, and suitable control- 
ling legislation has been already adopted in most civilised countries. 



62 FOODS AND FOOD PREPARATIONS 

The prevention of adulteration and contamination of milk is a 
matter of vital importance from both an economic and hygienic 
standpoint. Children, who are so largely dependent upon milk, do 
not well tolerate its adulteration, and milk is so much used as a raw 
food — perhaps more than any other one article of diet — that its care- 
ful inspection in regard to contamination by disease germs or adul- 
terants is imperative, and the constant vigilance of the health boards 
of large cities is required to protect the public from imposition. 
According to H. D. Chapin and G. B. Fowler, of the Milk Com- 
mission appointed by the Medical Society of the County of New 
York to investigate the milk supply of that city in 1900, " over 
6,000 children under five years died in New York city from diar- 
rhoeal diseases largely due to drinking old and contaminated 
milk." 

It is better and simpler, however, for much of the inspection to 
be done at the dairy farms, and in many parts of this country the 
State boards of health appreciate the importance of this matter, and 
the sale of milk from diseased cows is prevented at first hand. When 
a cream separator at a creamery is cleaned it is often found to con- 
tain a residue of manure, hairs, dirt, and perhaps pus and blood from 
inflamed udders. 

The examination of milk requires the adoption of a legal standard 
of quality. In New York city the Health Board depends chiefly 
upon the use of the lactometer above described. (See Estimation of 
Solids in Milk, page 59.) In States such as Massachusetts, Rhode 
Island, and Maine a chemical analysis is required by law. The 
normal specific gravity established is 1.030 (in New York 1.029), 
and the normal average amount of cream is 8 per cent by volume. 

The inspection of milk in all large cities and towns is made at 
the railway stations or ferries where the cans are received. The 
examination is under the direction of expert officers, usually mem- 
bers of the local health board. It is impossible and unnecessary to 
examine all the milk brought in, but the officers make frequent 
seizures and destroy at once all milk found below the legal standard. 
Milk sold in shops and otherwise must also be occasionally exam- 
ined, for its dilution and adulteration is very easy and profitable to 
the unscrupulous. Gross impurities in milk, such as dirt, hair, etc., 
may be removed by filtration through absorbent cotton. A few 
germs are also removed in this manner. A noted milk dealer of Ber- 
lin, who dispenses 60,000 quarts of milk daily, forces it through 
gravel filters from below upward, thereby removing the gross im- 
purities. 

Milk may be altered by — 

1. Addition of water, pure or impure. 2. Addition of colouring 
matter. 3. Addition of preservatives. 4. Addition of substances 
used for thickening after dilution. 



ANIMAL FOODS 63 

1. The commonest method of adulterating milk, and the one 
often most difficult of detection, is by dilution with water. If the 
water thus used is pure it does no harm other than to defraud the 
consumer ; but if impure, as it often is when drawn from wells near 
manure heaps, in barnyards, or country privies, it may prove fatal. 

2. The normal whiteness and opacity of milk is due to its fat glob- 
ules. If milk has been much diluted it becomes pale and bluish, and 
both milk and cream are sometimes artificially coloured with anilines 
or other pigments. This form of fraud is less injurious to health 
than the others, for but very minute quantities of colouring matters 
are employed. Annotto is the commonest dye used to impart a 
yellow colour to milk, cream, and butter. It is prepared from the 
seeds of a tropical American tree (Bixa orellana). It is detected by 
allowing the milk to stand in a tall glass, when the lower stratum 
will contain the pigment associated with the casein instead of re- 
maining colourless, while the naturally yellower cream floats on top 
(Hird). The cow's food may sometimes colour the milk red or pink, 
and it may be so stained by traces of blood, in which latter case the 
lower layers are of deeper hue than the upper. 

3. Various substances are added to milk and its products — con- 
densed milk, butter, cheese, and koumiss — to keep them from sour- 
ing. These are usually sodium bicarbonate, borax, or boric acid. 
Salicylic acid and formaldehyde are less often used. In small quan- 
tities they do not affect its taste or hurt the digestion of adults, but 
they may be injurious and even fatal to infants, and their use should 
never be tolerated. Salicylic acid is sometimes put into beer for a 
similar purpose, although this is prohibited by law. The presence 
of boric acid is detected by mixing one part of milk with two parts 
each of hydrochloric acid and saturated turmeric tincture. After 
drying on a water bath and adding a little ammonia, a dark-blue 
colour appears which changes to green. 

4. Both milk and cream, after dilution with water, are sometimes 
thickened again with such substances as flour, arrowroot, farina, 
whiting, chalk, tragacanth, or carbonate of magnesia, which disguise 
the natural blueness of the attenuated fluid. Effervescence in milk 
produced by addition of a strong mineral acid shows the presence of 
carbonates. Sugar is added to raise the specific gravity of diluted 
skimmed milk. 

Milk is contaminated or rendered unfit for use by — 
1. Improper or poisonous foods eaten by the animal. 2. Poor 
condition of the animal, due to nursing, worrying, etc. 3. Con- 
tamination by disease germs from the cow. 4. Contamination by 
extraneous disease germs. 5. Souring and decomposition. 6. Ab- 
sorption of bad odours. 

1. The colour of milk is affected by various substances ingested 
by the cow ; thus madder turns it saffron, rhubarb makes it red or 



64 FOODS AND FOOD PREPARATIONS 

yellow (Mosler), and it is coloured blue by some drugs. The colour 
is then uniform throughout the milk, and not superficial as in the 
case of the blue imparted by the growth of fungi, as described below. 
If milk be made blue by addition of litmus the solution will be red- 
dened by action of such bacilli as the lactic-acid bacillus, the bacillus 
typhosus, and the streptococcus pyogenes. 

Cows fed on brewers' swill or refuse of glucose factories, or cows 
allowed to eat decaying autumn leaves, garlic, certain injurious 
meadow plants, or strong-smelling plants like cabbages, turnips, 
and onions, will give unhealthy, strong-smelling, bad-tasting, or de- 
teriorated milk. Beets tend to make cow's milk acid. Cows should 
not be given unclean water to drink. Offensive odours and tastes 
imparted to milk through the cow, or by absorption from surround- 
ing substances, are most intense while the milk is fresh ; whereas 
if due to bacteriological influences, they only become apparent after 
some hours, and go on increasing. H. Weller found nearly i per 
cent of alcohol in milk from cows fed on distillery slops which con- 
tained 6 per cent of it. 

2. The milk first secreted after calving (colostrum) contains 
more albumin than casein. It is viscid, turbid, frothy, yellow, 
slightly acid, and coagulates on boiling. In the cow colostrum has 
a sickly odour, and is purgative even when cooked. It remains so 
for about a month after parturition. Colostrum corpuscles may be 
easily detected by microscopic examination. 

The bulling cow may be highly nervous during ovulation, and, as 
a reflex consequence, her milk becomes acid. 

Cows which are teased and worried by dogs or otherwise, or 
made to exercise too much, give milk which sours easily and dis- 
agrees with infants. Underfeeding makes the animal give inferior, 
watery milk. 

3. Cows suffering from certain diseases may transmit them 
through their milk to man, although this method of infection is less 
common than that through milk to which germs have had access in 
process of handling or transportation. The principal diseases which 
may be derived from the cow through her milk are tuberculosis and 
diphtheria. 

The Massachusetts Society for Promoting Agriculture, in a re- 
port upon " The Infectiousness of Milk," confirms the fact that milk 
from cows having tubercular udders is infectious to man. (This 
statement is contradicted by Koch, who, in common with several 
other observers, has claimed that human and bovine tuberculosis 
are non-interchangeable.) Tubercle bacilli were also demonstrated 
in the milk of twelve out of thirty-six cows having tuberculosis, 
but whose udders were not affected. The inference is drawn from 
the report that 3 per cent of the milk furnished to Boston is in- 
fected. It is estimated that 6 per cent of all cows are tubercular. 



ANIMAL FOODS 65 

Tubercular milk is of poorer quality, thinner, and bluer than normal 
milk. 

Cases have been reported of infection of a nursing infant through 
a tubercular mother's milk, and calves are undoubtedly so infected 
through cows ; but it must be remembered that the infant is much 
exposed to infection by its mother's sputum, and may inhale dried 
sputum from beneath her bedclothing or within the room. 

However, the presence of tubercle bacilli has been indubitably 
demonstrated at least a half dozen times in human breast milk. 
Tabes mesenterica and tubercular meningitis in children have been 
caused by infected milk. 

The foot-and-mouth disease of cattle is transmitted to man if the 
milk of cows so affected be drunk without boiling, which destroys 
the germs (Bollinger). This disease is transmitted even when the 
milk is diluted ten times or taken in coffee or tea, but adults must 
drink a good deal of it in order to become affected. Butter and 
cheese made from such milk also carry the infection (Schneider). 
The foot-and-mouth disease diminishes the quantity of milk given by 
the cow by one half, and the milk coagulates too quickly and has a 
yellowish colostrum-like appearance. If the disease be severe the 
milk separates into slimy coagulse and whey, and, on boiling, curdles 
in stringy masses. In other cases the taste is acid, and on standing 
twelve hours a yellow sediment is precipitated with a nauseous, ran- 
cid odour. The milk becomes infected from sores upon the nipples. 

4. Extraneous disease germs may find their way into milk 
through contact with unclean hands, or from polluted water used for 
dilution, or for washing cans and pans. 

Soxhlet says that if mother's milk were sold like cow's milk after 
as much careless handling, it would produce as much disease. 
Calves have been known to acquire diarrhoea when fed milk from 
unclean pails, and the animals were cured by allowing them to suck 
the very cows that had been milked into the pails. According to 
Sedgwick, milk may contain a million bacteria to the cubic centimetre 
after its journey from cow to table. 

Cow's milk is too often tainted with excrementitious matter from 
the stable or cow yard. The cows lie upon foul bedding, or be- 
spatter their udders continually in barnyard filth. Soxhlet has said 
that in judging the quality of milk one should consider " not so much 
what the cow fed on, as rather what kind of cow dung the milk 
contains." 

The following data from the report of a commission of disin- 
terested physicians upon the " Walker-Gordon guaranteed milk " 
from the dairy at Plainsboro, N. J., exhibit an ideal system of cleanli- 
ness. Each milkman before milking is required to cleanse his hands 
in hot water with soap and a nail-brush ; he then dons a clean white 
linen suit from the sterilising chamber, and takes a clean towel and 



66 FOODS AND FOOD PREPARATIONS 

milking-stool ; he is not allowed to moisten his hands with the milk 
in milking, and he must wash his hands each time before milking 
another cow. All cows must have given a negative tuberculin test, 
and all are groomed twice a day before milking. Pine shavings are 
used for bedding. The milk is drawn into pails with small openings, 
to exclude droppings from the animal's belly. The milk is strained 
through sterilised absorbent cotton and placed in a cooler, which 
reduces the temperature to 40 F. within twenty minutes after leav- 
ing the udder. It is then bottled and stored in ice water ready for 
shipment. 

Milk carelessly transported promptly absorbs germs from the air 
or from unclean receptacles, and it is an excellent culture medium 
for rapid growth of such germs as those of tuberculosis, scarlatina, 
diphtheria, and typhoid fever, which may gain access to it in that 
manner. When local epidemics of such diseases break out, there 
should always be a thorough investigation of the sources of milk 
supply, and a bacteriological examination of the milk itself should 
be instituted. Many persons imagine that a chemical analysis is 
sufficient, but this is useless for .detection of disease germs. 

Severe epidemics of typhoid fever have of late years been attrib- 
uted to infected milk by H. E. Smith, at Waterbury, Conn. ; by L. H. 
Taylor, at Wilkesbarre, Pa. ; and by Littlejohn, who traced the origin 
of sixty-three cases to one dairy. Fourteen cases of typhoid fever 
occurring in East Barrington, N. H., in 1896, were traced to the 
eating of ice-cream contaminated by a milkman who had continued 
milking while himself suffering from the fever. No one who is 
nursing a case of typhoid or scarlet fever or diphtheria, or who in any 
way handles the discharges or clothing of such patients, should be 
allowed to touch milk or milk receptacles, much less to milk a cow. 

At Brewster, N. Y., Miller reported twenty-four cases of scarla- 
tina which occurred among those who drank the milk supplied by 
one dairyman while his daughter had scarlet fever. The disease was 
not otherwise prevalent in the town at the time. 

E. Hart reported at the Seventh International Medical Congress 
a series of epidemics in England the origin of which he had traced 
to milk. Of these, fifty were of typhoid fever, fourteen of scarlatina, 
and seven of diphtheria. 

The diphtheria bacillus has not thus far been proved to be trans- 
mitted direct from the cow to man, but cows inoculated under the 
shoulder with diphtheritic microbes exhibit the germs in the milk 
after developing local lesions of the udders. Those epidemics of 
diphtheria the spread of which has been attributed to milk have 
probably been due to contamination through the handling of the 
milk by milkers or dairymen having the disease themselves or who 
have been in close contact with it. In this country Goodwin and 
W. H. Stillwin have both reported such epidemics occurring in 



ANIMAL FOODS 6? 

Michigan in 1879. W. J. Howard, Jr., studied an epidemic of 100 
cases in 49 houses in Ashtabula, Ohio, in 1894, which he is confi- 
dent was referable to a milk supply delivered by boys who had 
severe angina at the time, although the bacillus diphtheria was not 
found in their throats. The New York Health Board reported the 
discovery of the germs in cheese made by a milkman in whose family 
diphtheria was present. 

A mould, the Oidium lactis, or penicillium, and the Bacterium cyano- 
genum are germs which produce a blue colour in milk and sour 
it. The mould also grows upon cream cheese. This colour appears 
first upon the surface if the milk be not agitated, and it differs 
from the uniform blue imparted by adulteration with water, or by 
poisonous plants, drugs, etc. Milk thus affected is irritant, and may 
cause febrile gastritis, stomatitis, or diarrhoea. 

Milk is coloured lemon yellow by the Bacterium synxanthum 
(Ehrenberg), and red by chromogenic fungi. 

The fungi and germs themselves do not impart the colours, but 
develop various anilines — aniline blue, fuchsin, etc. — from the casein 
(Schroter). 

" Clouty cream " is produced by germ action. 

5. There are ten different varieties of bacteria which are capable 
of inciting lactic-acid fermentation of the milk sugar (Leeds), all of 
which cause the milk to " sour " and curdle, and some, but not all, 
simultaneously develop carbonic acid and alcohol. A large propor- 
tion of the bacteria of milk rises with the cream to the surface (Free- 
man). Milk may be really decomposing although it has not yet 
coagulated. 

The first process, that of the formation of lactic acid, is a pre- 
liminary to the normal digestion of milk, but the second is abnormal 
and interferes with it. The sour milk curd may be redissolved by 
neutralisation with alkalies. 

The Bacillus acidi lactici may sour the milk before it is ingested, 
or, like many germs, their action may not be apparent before swal- 
lowing the milk, but it begins immediately thereafter in the stomach. 

Good, clean, uncontaminated milk should keep fresh exposed 
in a clean room at the ordinary temperature of 68° F. for forty-eight 
hours without souring and coagulating. But if the air is much 
warmer, or if the milk is tainted in any manner, it will sour in a few 
hours. Boiled milk keeps fresh rather more than half as long again 
as fresh milk. 

6. The absorbent power of milk is strong, and it may acquire 
a strong odour from substances kept in its vicinity. It may acquire 
a bad flavour at the same time, or may have the odour alone. 

If left in a refrigerator with stale cheese, ham, onions, decompos- 
ing meat, etc., it soon becomes spoiled in this manner. Milk easily 
absorbs the odour of tobacco, camphor, or of turpentine from fresh 



68 FOODS AND FOOD PREPARATIONS 

paint, and, in fact, the odour of almost any volatile substance. It 
should never be left exposed in the sick-chamber or in a bathroom, 
or near a waste pipe. 

PROPHYLAXIS AGAINST MILK INFECTION 

As prophylaxis against milk infection certain precautions are 
necessary, and it should be the duty of physicians to educate public 
sentiment in regard to their importance as a means of restricting the 
spread of infectious and dietetic diseases. 

For transportation from the country to the city, milk is usually 
taken from the farms in forty-quart tin cans, which should be filled 
full and tightly covered to prevent churning and souring. Some 
railways supply refrigerator milk cars, which are hung upon specially 
constructed springs, to prevent as far as possible agitation of the 
cans. At some dairies the milk is put, directly after milking, into 
glass bottles previously sterilised by washing and steaming, which 
are then tightly corked. If pails, pans, or cans are used, their abso- 
lute cleanliness must be insured by frequent careful washing and by 
occasional scalding with hot water. This destroys germs or ferments 
which would otherwise contaminate the fresh milk and soon sour 
it. The bottles are sealed and stamped " Certified Milk " before 
being sent to market. 

Many large dairies now employ a veterinarian, whose duty it is to 
daily examine all the cows and report on their health, and on the 
hygienic condition of the stables, yards, etc. 

Nothing is more disgusting than allowing the manure-besmirched 
tails of ungroomed cows to contaminate the hands of milkers, or the 
milk itself, and yet this is constantly happening. 

The question of prophylaxis is of such universal interest that 
the admirable rules formulated by Vaughan are here quoted in full : 

" a. The cows should be healthy, and the milk of any animal 
which seems indisposed should not be mixed with that from the 
healthy animal. 

41 b. Cows must not be fed upon swill or the refuse from brew- 
eries or glucose factories, or upon any other fermented food. 

" c. Milch cows must not be allowed to drink from stagnant pools, 
but must have access to fresh pure water. 

" d. The pasture must be freed from noxious weeds, and the barn 
and yard must be kept clean. 

" e. The udders should be washed and then wiped dry before 
each milking. 

" /. The milk must be at once thoroughly cooled. This is best 
done in the summer by placing the milk can in a tank of cold water 
or ice water, the water being of the same depth as the milk in the 
can. It would be well if the water in the tank could be kept flow- 



ANIMAL FOODS 69 

ing, and this will be necessary unless ice water is used. The tank 
should be thoroughly cleaned each day to prevent bad odours. The 
can should remain uncovered during the cooling and the milk should 
be gently stirred. The temperature should be reduced to 6o° F. or 
lower within an hour. The can should remain in cold water until 
ready for delivery. 

" g. Milk should be delivered during the summer in refriger- 
ated cans or in bottles about which ice is packed during trans- 
portation. 

" h. When received by the consumer it must be kept in a clean 
place and at a temperature some degrees below 6o° F. 

" If all the milk used in the artificial feeding of infants could be 
obtained and marketed with the care demanded by the above rules, 
milk infection would be practically unknown and the sterilisation 
of the infant's food would be unnecessary." 



USES OF MILK 

The following are the more important uses of milk : 

1. As an infant food. 

2. As a food for adults. 

3. As a source of special food products and derivatives, such as 
koumiss, cream, butter, and cheese. 

4. As a diuretic. 

5. For its soothing effect on diseased mucous membranes of the 
alimentary canal. 

6. To loosen cough (when given hot). 

7. As a prophylactic against lead poisoning. 

8. As a vehicle for the administration of other foods. 

9. As a vehicle for the administration of medicines. 

10. For rectal injection. 

The first three of these uses are so important that they will 
receive separate detailed consideration (see Diet in Infancy, page 
748, Adaptation of Milk for the Sick, page 73, and Milk Deriva- 
tives, page 93) ; the others may be briefly referred to here. 

4. The diuretic action of milk in some persons is very pro- 
nounced, while in others it is not noticeable. It is due to the two 
ingredients, water and lactose or milk sugar. The water acts by 
increasing the volume of blood and the renal blood pressure. The 
lactose probably acts directly by stimulating the renal epithelium. 

Lactose has been employed with doubtful success as a diuretic 
in dropsies and some forms of renal disease. The dose is twenty to 
thirty grains. 

The mineral salts and the water of milk are speedily absorbed 
by the mucous membrane of the stomach, and in some persons this 
process is so rapid that milk taken by the tumblerful into an empty 



70 FOODS AND FOOD PREPARATIONS 

stomach has a very decided diuretic effect within an hour. This 
action may be further promoted by drinking a cup of black coffee. 

5. Milk is undoubtedly soothing to the mucous membranes of the 
alimentary canal. It is often the only variety of food which can be 
borne by an inflamed or irritable stomach or in some forms of intes- 
tinal disease. It is equally soothing in the rectum. 

6. A few sips of hot milk or hot milk and Vichy will often allay 
an irritable cough, and favour the expectoration of tenacious bron- 
chial mucus. 

7. Milk is sometimes employed among type founders as pro- 
phylactic against lead poisoning. It is claimed by Hirt that if a 
quart or two be drunk daily, poisoning never occurs. 

8. As a vehicle for administration of other foods for invalids, such 
as egg albumin, beef-meal, meat juice, peptonoids, cocoa, spirits, etc., 
milk is most useful. 

9. As a vehicle for the administration of many medicines and 
insoluble powders, such as calomel, disagreeable-tasting drugs, like 
potassium iodide, salicylates, opium, etc., milk is often very service- 
able. Sulphonal given in hot milk acts better than if prescribed 
alone. 

10. Milk is employed in nutritive enemata, alone or with beef 
juice, beef peptonoids, spirits, etc. From one to two or more ounces 
are given at a time, after cleansing the rectum. A little laudanum 
may be added, and a towel should be held against the perinaeum to 
aid in the retention of the milk. When the circumstances admit, it 
is advisable to pass a long catheter and inject the milk through it as 
far as the sigmoid flexure, while the patient is supported upon the 
hands and knees. The higher up the milk is injected, the more read- 
ily it is absorbed, and the circulation of the rectum is such, that 
whatever ingredients of the milk are taken up by the venous capilla- 
ries of the lower portion pass to the vena cava, whereas the ingre- 
dients absorbed by the superior haemorrhoidal or the sigmoid vessels 
are carried directly to the vena porta and liver, where they are as- 
similated more promptly. The lymphatic capillaries also assist in 
the absorption. 

The simple mucous secretions of the rectum have no proper di- 
gestive action upon milk (Czerny). but they may sometimes cause 
putrefaction of its albuminous matter, with formation of tyrosin, 
indol, etc. (Marckwald). It therefore facilitates absorption to have 
the milk previously digested by pepsin or pancreatin. Patients hav- 
ing ulcer or carcinoma of the stomach, any intestinal obstruction, or 
irritant vomiting, may be kept alive for many weeks by the exclusive 
use of nutrient milk enemata. (See Food Enemata.) 

Attempts to get milk into the circulation by rubbing it into the 
skin and by soaking portions of the body in milk baths have proved 
of no avail, for it is not absorbed in that manner. 



ANIMAL FOODS 7 1 

The intravenous injection of milk has been occasionally used in 
cholera collapse, post-partum haemorrhage, etc., and in some few 
cases it has been found satisfactory, but since saline injections have 
proved more efficacious, those of milk have been abandoned. Milk 
has also been injected into the peritoneal cavity, but without much 
benefit. It has been given hypodermically in doses of four grammes 
(Menzel). One patient was kept alive sixty-three days in this man- 
ner (Whittaker). The milk thus injected is absorbed within an hour. 

MILK DIGESTION 

Normal Digestion. — Milk is not altered in the mouth, but on 
reaching the stomach the casein is precipitated by a curdling fer- 
ment, called rennin. The curds, or coagulae, vary in size and tough- 
ness according to the quality of the milk, its degree of dilution, and 
other circumstances. 

The gastric hydrochloric acid also coagulates milk by neutralis- 
ing the alkali which holds the casein in solution. Hence milk be- 
comes really a solid food almost as soon as it enters the stomach. 
In coagulating, the curds entangle the fat globules, but they are 
soon dissolved by the ferment of the gastric juice (pepsin) and con- 
verted into peptones or intermediate products called albumoses. 
The fat globules are again liberated, their albuminous envelopes are 
dissolved, and they coalesce to larger droplets, in which condition 
they pass with the chyme into the intestine. The usual period for 
the digestion of milk in the stomach by normal gastric juice occupies 
about three hours. 

The salts and water of the milk, and possibly to some extent the 
sugar, are absorbed in great part from the stomach wall. In proof 
of this is the fact that the diuretic action of milk is often obtainable 
within half the time required for the complete digestion of the al- 
buminoids. When not absorbed by the stomach they pass into the 
intestine and are absorbed through the villi. 

Those curds which are not fully dissolved by the gastric juice 
may enter the duodenum, where their digestion is completed by the 
pancreatic juice. The latter saponifies the fat which is absorbed by 
the lacteals of the villi. In the digestion experiments of C. H. Woods 
and L. H. Merrill (U. S. Department of Agriculture Bulletin Xo. 85, 
1900) the digestibility of milk casein was always increased by the 
addition of bread to the milk. 

Rennin. — Rennet is the name given to an infusion of the middle 
stomach of the calf in brine which possesses special milk-curdling 
power which is due to a ferment called rennin. 

This milk-curdling ferment is believed to be developed by the 
action of acids from an antecedent material called zymogen. Rennin 
is not obtainable from the human stomach in large quantity, but it 



72 FOODS AND FOOD PREPARATIONS 

undoubtedly exists in the gastric juice, for pure pepsin has scarcely 
any curdling action upon milk ; moreover, milk may curdle in either 
neutral or alkaline media in which pepsin is inert. Rennin is most 
active in an acid medium, but it also works in the alkaline pancre- 
atic juice. It possesses little proteolytic power. It is believed to 
exist more abundantly in the infant stomach than in that of the adult. 

Rennet may be prepared as a powder ; it is sold by grocers in 
alcoholic solution, and when added to milk which is gently warmed, a 
light coagulum is formed, causing the milk to partially solidify. The 
coagulum contracts and squeezes out fluid, which constitutes whey. 
The rennetised milk when flavoured with vanilla or powdered cinna- 
mon or nutmeg makes an agreeable invalid food or dessert, which is 
highly nutritious, for it still contains all the original ingredients of 
milk. 

Abnormal Digestion. — In cases of indigestion from various causes 
the curds may remain undissolved in the stomach, eventually irritat- 
ing it and causing vomiting, or they may pass along the intestine 
and be voided unaltered in the stools. This occurrence is more fre- 
quently noticed in young infants than in adults. 

Milk which disagrees in the stomach forms large and somewhat 
tough coagulse of casein, which are with difficulty dissolved by the 
gastric juice. Many substances may be added to milk which by 
their mechanical presence will prevent this occurrence, and hence 
favour the action of the gastric juice. Excessive acidity of the stom- 
ach due either to hypersecretion of hydrochloric acid or the presence 
of organic acids, especially lactic, derived from the food or fermenta- 
tion processes, modifies the digestion of milk ; the lactose is altered 
into lactic acid and the casein is promptly coagulated. The alkaline 
salts of milk are split up and phosphoric acid is liberated, and com- 
plicated fermentative changes ensue which are as yet imperfectly 
understood. All this causes more or less gastro-enteric irritation, 
resulting in diarrhoea. 

When milk or cheese remains too long in the stomach or intes- 
tine a further fermentation is excited accompanied by a neutral or 
alkaline reaction, and which results in the final production of butyric 
acid, and sometimes of other substances, such as leucin, tyrosin, and 
ammonia. But while free hydrochloric acid exists in the contents of 
the stomach, the organic acids — lactic, butyric and acetic — which are 
associated with milk fermentation are unlikely to develop. 

Cow's milk may readily become acid from alteration in the rela- 
tive amount of potassium biphosphate and the two-thirds phosphate 
of potassium. The former, if present in excess, hastens coagulation 
and an acid reaction. When warm the milk may again become alka- 
line (Soxhlet, Heintz). 

These facts explain the frequent necessity of using antacids, such 
as lime water or sodium bicarbonate, with infant milk food. Mucous 



ANIMAL FOODS 73 

fermentation of the proteids makes the milk slimy, and it becomes 
stringy on boiling. 

Milk, according to Rubner's experiments, yields more bulky resi- 
due in the feces than either eggs or meat, yet its nutritive ingredi- 
ents are very perfectly absorbed. From 8 to 10 per cent approxi- 
mately of the solids of milk is eliminated in the stools. 

ADAPTATION OF MILK FOR THE SICK 

When patients object to the taste of milk alone, they can be often 
induced to take large quantities by using it in various combinations 
or preparations, or by disguising its taste. Many patients when or- 
dered a milk diet positively assert that they cannot endure the taste 
of milk ; that it always nauseates them, or that it makes them bilious 
and constipated, and excites headache. They say, perhaps, that they 
have faithfully tried to drink it before, and never could tolerate it ; but 
scarcely any one person has ever tried all the different methods of 
taking milk, and it does not follow that because it once disagreed 
several years before it will again. The objection to the taste can 
always be overcome by a little tact and perseverance, and there are 
very few persons who cannot assimilate a more or less exclusive milk 
diet for a few days or weeks if the milk is properly given, and, if 
necessary, artificially digested for them. Their previous unhappy 
experience is probably due to having taken a large dose of undiluted 
rich milk which promptly coagulated, soured, and was rejected, ex- 
citing all the distaste which they have treasured against it. 

When, as in some febrile cases or in acute Bright's disease, a milk 
diet is imperative, such patients should begin with but a teaspoonful 
or two at a time, repeating it once in ten or fifteen minutes. If milk 
is only taken slowly enough into the stomach, and mingled on the 
way with saliva, like other food — eaten rather than drunk — it is im- 
possible for it to form the large tough curds that it does when poured 
down by the tumblerful, like a dose of salts. By degrees the patient 
will be convinced of his ability to retain it, and then the dosage may 
be increased; making such further changes in the preparation of it 
as occasion demands. 

In all cases where there is a tendency for milk to disagree it is 
better to give it alone to the patient, by which means various expe- 
dients used to increase its digestibility may be better tested. Patients 
will often digest both milk and beef broth or milk and whisky when 
these substances are given at alternating intervals of one or two 
hours, whereas if taken in conjunction they give rise to dyspepsia. 

The methods of altering milk to suit the taste or digestive re- 
quirements are so numerous that it will be found convenient to group 
them under the following headings, although the classifications are 
somewhat arbitrary and here and there may overlap : 
7 



74 FOODS AND FOOD PREPARATIONS 

I. Methods of altering the taste of milk. 

II. Methods of improving the digestibility of milk. 

III. Methods of predigestion. 

IV. Methods of sterilisation and preservation. 

The first method beguiles the patient into taking larger quantities 
of milk without tiring of it ; the second aims at preventing the for- 
mation in the stomach of dense tough coagulae which are difficult of 
solution and digestion by an enfeebled gastric juice ; the third, by 
artificial digestion, relieves a weak stomach of much labour; the 
fourth prevents the accession of poisonous germs which would 
excite malfermentation and indigestion. 

I. Methods of altering the Taste of Milk 

When patients object to the taste of raw milk or tire of it, it may 
be flavoured in a variety of ways. When there is no objection on 
the score of the nervous system, a teaspoonful or two of black coffee 
is one of the best means at hand, or a little of the extract of coffee 
may be added. Very weak tea may be preferred. Caramel is an- 
other excellent flavouring substance which may be freely employed, 
and ginger is also used. Other patients may take a little chocolate 
or cocoa or cocoa nibs infusion with their glass of milk. Some 
prefer the addition of common salt or a little black pepper. The 
various meat extracts, fluid or solid (see Meat Preparations, pages 
801, 804), may often be used to advantage. When alcohol is not 
contraindicated many patients are willing to drink much milk 
in the form of weak punches, or as eggnog in which cognac, 
whisky, sherry, or rum may be employed to disguise the pure- 
milk taste. 

The various malt extracts are enjoyed by some when given in 
milk, and their disagreeable sweetness is thereby removed. A tea- 
spoonful of malt may be added to a pint of milk which is gently 
warmed for half an hour, after which it is boiled for twenty minutes. 
This prevents the formation of large curds. 

None of these additions materially affect the nutritive value of 
milk, and the occasional variety which may be secured by experi- 
menting with different substances will usually overcome all preju- 
dices. I have often induced patients to take large quantities of 
junket flavoured with a little spice (see Receipts for Invalid Foods), 
not realising that they were really eating only pure milk which had 
passed into the first stage of digestion. Patients who object to milk 
because they have to drink so much fluid may take the same quan- 
tity in the form of junket because they can eat it with a spoon. 

Much milk may be disguised sometimes in custards, gruels, etc., 
where there is no objection to the addition of other easily digestible 
foods. 



ANIMAL FOODS 75 

II. Methods of improving the Digestibility of Milk 

1. Skimming. 

2. Boiling. 

3. Dilution with water. 

4. Dilution with alkaline and aerated waters. 

5. Dilution with amylaceous foods. 

6. Addition of alkalies, acid and other substances. 

1. Skimmed milk is the residue after removal of the cream. It 
contains water, 90.63 per cent ; proteid, 3.06 per cent ; fat, 0.79 per 
cent ; sugar, 4.77 per cent, and a residue of salts. It thus retains 
almost 10 per cent of solids. 

Skimmed milk is well digested by those patients whose stomachs 
do not tolerate fat in any form, but it will not long support life, and 
attempts which have been made to cure certain diseases by a 
skimmed-milk diet have signally failed. Donkin advocated its use to 
the extent of six to eight pints daily. 

It may be employed temporarily in the milk cure for Bright's 
disease, dropsies, and in the treatment of neurotic hysterical cases. 

Yeo advises gouty subjects to drink ten minutes before each meal 
a breakfastcupful (eight ounces) of hot skimmed milk and water with 
the addition of a small saltspoonful each of potassium bicarbonate 
and salt. This is a good means of prescribing an alkali, but there 
is no special advantage in the skimmed milk. 

2. Boiling. — Boiled milk exhibits a thin scum of albumin upon the 
surface which entangles some of the fat globules, and which is quickly 
replaced by another after removal. This scum should not be served 
to invalids. There is much discussion as to whether infants should 
ever be given raw cow's milk, or only that which has been previously 
boiled, and authorities are divided upon the matter. Certainly in 
most cases raw milk, if pure, provokes no harm. Boiling the milk 
arrests the development of germs and fungi with which it may have 
become contaminated, and may thus prevent the spread of some 
diseases, and it retards the process of " souring " and coagulation. 
Boiling expels about 3 per cent of gases — carbon, nitrogen, and 
oxygen (Hoppe) — and the loss of oxygen diminishes the formation 
of lactic acid and consequent souring. It alters the taste of the milk 
somewhat, and makes it " flat." The flatness is removed by agitating 
the milk with air by pouring it back and forth into two cups held 
a little distance apart ; or it may be removed by the addition of any 
aerated water. As a rule, boiled milk is preferred hot, but some 
persons enjoy it cold. 

It is a prevalent idea that milk is in general more digestible if 
boiled than if raw, but the results of experiment do not wholly 
confirm this view. Crolas has demonstrated that boiling has no 
influence upon either the lactose or casein, but it slightly in- 



y6 FOODS AND FOOD PREPARATIONS 

creases the free soluble phosphates, which he regards as an ad- 
vantage. 

Radnitz found by experiment that young animals absorb 9.4 per 
cent of albuminoids from fresh milk, but only 5.7 per cent from 
boiled milk, hence a larger quantity of the latter must be drunk to 
obtain the same nourishment which is derived from raw milk. 

According to Vasilieff, the envelopes of the oil globules are al- 
tered by heat, and he claims that 50 per cent less fat is absorbed. 
This seems too high an estimate in view of clinical observation. 

Occasionally patients are made bilious and constipated by the use 
of boiled milk who digest it better raw, but the converse is also true : 
it is a matter of idiosyncrasy. It has decided advantage in diar- 
rhceal diseases, probably through the absence of germs and gases. 
In some cases it may be combined with thin chocolate or cocoa. 

" Scalded milk " is heated to about 150 F., or practically " Pas- 
teurised," by pouring on boiling water. Thus treated, milk remains 
fresh a little longer than when raw. 

3. Dilution with Water. — The dilution of milk is accomplished by 
adding plain water, either hot or cold, in the proportion of one part 
to two or three of milk. If the milk is exceptionally rich in cream 
and casein this simple means will often be sufficient to ensure its 
better digestion, for the curds become both smaller and softer. 

4. Dilution with Alkaline or Aerated Water. — Lime water may be 
added in the proportion of two to four or more tablespoonfuls to 
each tumbler of milk, taken cold. In cases with much acidity of the 
stomach the lime water should be mixed in the proportion of one half 
or even two thirds. When so given, the taste of the milk is so little 
altered that very few patients object to it, and some even find it 
more agreeable. If diarrhoea or nausea is present they are controlled 
to some extent, but on the other hand constipation is increased by 
the use of lime. When the latter exists it is better to dilute with 
Vichy or carbonic-acid water. If lime water is added to neutralise 
the acidity of cow's milk the temperature of the mixture should not 
be raised above that of Pasteurisation — 160 to 170 F. — because the 
albuminoids are more or less decomposed in a boiling alkaline solu- 
tion. It is better to separately sterilise the lime water and add it 
afterwards. 

Barley water may be used as a diluent for milk in diarrhcea, but 
oatmeal water is better for constipation. 

Aerated waters, such as carbonic-acid water, alkaline Vichy, 
bottled plain soda, or Apollinaris, may all be added to milk, in any 
desired proportion. In cases of fever four ounces of a mixture made 
with equal parts of the diluent may be given every hour, or eight 
ounces every two hours, up to two and a half or three pints of milk 
per diem. 

Most of these waters are best used with cold milk, but for many 



ANIMAL FOODS JJ 

persons hot milk and Vichy make a very agreeable combination, 
which is often soothing to the obstinate cough of bronchitis. The 
gaseous waters relieve the " flatness " of the milk, and prevent the 
after-taste of it in the mouth, of which many patients complain. The 
mixtures with Vichy and lime water are especially serviceable where 
extreme irritability of the stomach is present with a tendency to the 
immediate rejection of all fluids. 

5. Dilution with Amylaceous Foods. — Any form of starchy food — 
flour, arrowroot, etc. — serves as a mechanical diluent of milk by 
mingling with it and preventing the precipitation of tough curds. 
Bread and milk, or crackers and milk, serve the same purpose, and, 
being semisolid, have the further advantage that they must be eaten 
slowly and mixed with saliva. 

When infants vomit their milk it may be temporarily attenuated 
with either barley water or oatmeal water added instead of plain 
water, and in the same proportion — i. e., one third or one half. The 
much-extolled starchy " infant foods " are less useful as foods than 
they are as diluents of milk, and if used temporarily with the latter 
object solely in view, they are less liable to produce rickets, scurvy, 
gastric catarrh, and other maladies. Whenever amylaceous sub- 
stances are selected to dilute milk for infants they should first be as 
far as possible converted into dextrin and glucose, for gummy dex- 
trin, saccharine, or even gelatinous materials are all better than crude 
starchy foods. 

For adults a tablespoonful of Mellin's or Nestle's food dissolved 
in an ounce of hot water and added to a glass of milk is both pala- 
table and nutritious in cases of phthisis or scrofula. 

6. Addition of Alkalies, Acid and Other Substances. — The addition 
of alkalies to milk renders it much more digestible for some persons. 
In hyperacidity of the stomach or in the presence of abnormal fer- 
mentation alkalies are beneficial as neutralising agents. On the other 
hand, in cases in which the gastric juice is very feeble or absent, 
artificially digested milk may prove more serviceable. 

The admixture of alkalies by reducing the acidity of the gastric 
juice makes the casein coagulate more slowly, and in flocculi rather 
than in large coagulse. 

Salt may be added — a saltspoonful to the tumbler of milk. This 
improves its digestibility for most persons, and renders it less likely 
to cause biliousness. Sodium bicarbonate, ten grains, or a salt- 
spoonful to the tumbler of milk, prevents malfermentation in the 
stomach. If hyperacidity of the stomach exists, sodium bicarbonate 
may prove better than lime water, which is but slightly antacid, for it 
contains but a half grain of lime to the ounce. On the other hand, 
if the gastric juice is too feeble to digest milk easily, it is sometimes 
a disadvantage to attenuate it still further with quantities of lime 
water, and sodium bicarbonate should be substituted to check the 



78 FOODS AND FOOD PREPARATIONS 

acid fermentation of the milk which the hydrochloric acid of the 
gastric juice fails to control. An excellent combination for an irri- 
table stomach is made by adding five or ten grains of this salt and 
two grains of cerium oxalate to each glass of milk. The cerium oxa- 
late has a sedative and tonic action upon the mucous membranes and 
tends to allay nausea and irritation in the stomach. 

Other substances sometimes added for gastric ulcer, etc., are 
sodium phosphate, saccharated lime, or a teaspoonful of milk of 
magnesia to the pint. A few drops of liquor potassse to the pint of 
milk are recommended by Bulkley for infants having eczema. 

Starr gives the following receipt for making saccharated lime for 
diluting milk for infants : 

Slaked lime, one ounce ; refined powdered sugar, two ounces ; 
mix, triturate, add distilled water, one pint. Shake occasionally for 
some hours in a bottle, let stand, and siphon out the fluid. 

Roberts recommends a powder containing 10 grains each of so- 
dium bicarbonate and common salt, and 5 grains of light magnesia, 
to be added to a tumblerful of one third hot water and two thirds 
hot milk. 

Edes strongly recommends the addition of hydrochloric acid to 
milk. Twenty minims of the dilute acid of the pharmacopoeia are 
stirred slowly, drop by drop, into a pint of milk which is gently 
warmed. A fine flocculent coagulum of casein floats in the whey, 
and the digestibility of the milk is improved, while a flat or disagree- 
able taste is avoided. 

Gelatin. — Gelatin may be employed in small quantity as an at- 
tenuant of milk. Starr gives the following receipt for its use : 

Soak a piece of white gelatin an inch square in half a cupful 
of cold water for three hours. Put the cup in a saucepan of 
water and boil until the gelatin dissolves. When cold it forms 
a jelly. For infants one or two teaspoonfuls may be put into 
each nursing bottle of milk. 

III. Methods of Predigestion 

1. Peptonised milk. 2. Pancreatinised milk. 3. Koumiss, kefir, 
matzoon, etc. 

1. Peptonised Milk. — The object of peptonising milk is to com- 
plete a portion of the digestive process outside of the body, and 
thereby relieve the alimentary canal of this work. A great variety 
of preparations of pepsin, peptonising powders, etc., are offered in 
market. 

In general they are pure, but they vary somewhat in rapidity and 
strength of action. The powder may be added some time before 
the milk is swallowed, and in this event it can only act in conjunc- 
tion with dilute hydrochloric acid. If added to the milk at the time 



ANIMAL FOODS 79 

of swallowing, the normal acid of the gastric juice supplies the 
proper reaction. 

The process of artificial peptonising consists in adding one of 
the numerous preparations of pepsin obtained at the pharmacist's to. 
fresh acidulated milk, and allowing it to stand in a bottle immersed 
in warm water at approximately the body temperature. A fermen- 
tation results in which the casein is more or less completely con- 
verted into albumoses. 

If the process be too long continued, further fermentation results, 
and the milk becomes very bitter. It is therefore checked after a 
few minutes, either by boiling the milk, which has the effect of de- 
stroying the pepsin, or by keeping it upon ice until ready for use, 
which inhibits the action of the ferment. 

Either peptonised or pancreatinised milk may be prepared in 
quantity for use by infants or invalids during the day, and if there 
is an ice chest to keep it in, it is better to do so, for then it is more 
uniform in composition. If ice is not at hand, the preparation 
should be freshly made for use each time, otherwise it will become 
bitter and spoil. 

2. Pancreatinised Milk. — Of recent years the use of pepsin for 
predigestion of milk has been gradually superseded by that of pan- 
creatin, which acts best in an alkaline medium. This ferment, like 
pepsin, may be preserved almost indefinitely in powdered form. 
Milk thus prepared is slightly yellow and less opaque than raw milk. 
The process may be conducted as follows : 

Add a pint of fresh milk to a gill of cold water in a clean ves- 
sel. Put in a tubeful of Fairchild's "peptonising powder " (pancre- 
atic extract 5 grains, and sodium bicarbonate 15 grains), or, instead 
of the pancreatic extract, substitute 1 to 2 drachms of " pancreatic 
solution " made by Parke, Davis & Co., stir well, and place in warm 
(not boiling) water for half an hour or until a slight bitter taste is 
present. 

This taste means that fermentation has proceeded far enough. 
To allow it to continue will make the milk unpalatable, and it is 
almost impossible to disguise the bitterness. Boiling for two or 
three minutes stops all further fermentation, and the milk should 
then be placed on ice until ready for use. Such milk will keep well 
for several hours. 

When used, serve alone cold, or add carbonic-acid water to dis- 
guise the taste. For adults a little coffee may be used for the same 
purpose. 

Pancreatinised Milk Gruel. — To a pint of cold fresh milk add a 
pint of thick milk gruel, boiling hot. The gruel may be made of 
sago, pearl barley, arrowroot, oatmeal, wheat flour, or other farina- 
ceous food, according to taste. The temperature of the mixture 
should be about 125 F. Add a tubeful of peptonising powder (15 



8o FOODS AND FOOD PREPARATIONS 

grains), and place on the side of the stove for two or three hours, 
avoiding great heat. Then boil to stop the fermentation. Strain, 
and keep on ice ready for use. The gruel disguises admirably the 
taste of the milk. 

When pancreatinisation is long continued the casein is completely 
digested, but the milk becomes too bitter for use. 

Legumin. — Legumin is a vegetable ferment which is said to make 
milk highly digestible for invalids by converting casein into a sol- 
uble albuminoid. This substance, which was lately introduced by 
Bovet, is also given as a food. 

3. Koumiss. — Koumiss (spelled also koumys and kumyss) is milk 
artificially prepared by simultaneous lactic acid and alcoholic fer- 
mentation. It was originally made by the natives in the steppes of 
southeastern Russia and other eastern countries as a refreshing and 
slightly intoxicating beverage. Of late years the idea has been ad- 
vanced that it has some beneficial or curative influence in chronic 
diseases, such as phthisis, chronic bronchitis, chronic gastro-intestinal 
catarrh, and other wasting diseases, and as a result the manufacture 
of koumiss has been extensively introduced into the United States, 
and at many pharmacies it can be obtained daily, freshly prepared, 
in pint or quart bottles. It is probable that a large share of the 
benefit claimed for the native " koumiss cure " is attributable, like 
most " cures," to the favourable climate in which the patients live, 
especially during the months of May, June, and July, where the air 
is dry, clear, and aromatic. 

Very advanced cases, and those having active fever, may not be 
benefited by the " cure," but koumiss may be given them at home. 
Koumiss is of great service as an easily digested food for many cases 
of obstinate gastric irritation and severe vomiting. In the latter it 
may be often tolerated when no other nutriment is retained. Its 
uses are therefore various both for infants and adults, and there are 
often cases in which it agrees better than pancreatinised milk or milk 
prepared in any other way. 

The Manufacture of Koumiss. — The manufacture of koumiss may 
be conducted by several different processes. In southeastern Rus- 
sia, especially in south Samara, the milk of a certain breed of mares is 
used, which is particularly rich in milk sugar but poor in fat and 
casein, and the animals are fed upon grasses which contain this sugar- 
forming material in abundance (Karrick). 

Mare's milk, as compared with cow's, contains much more sugar 
(6 per cent) and less casein and fat (less than 3 per cent) (Biel). 

The mares are light-coloured animals, unbroken, and are guarded 
with greatest care, not being allowed dry food, such as oats and hay. 
Pastured among mountains containing salt beds, they have access to 
running water, in which they can bathe frequently. They have large 
udders and abundant milk secretion, which is milked from four to 



ANIMAL FOODS 8 1 

eight times daily. The best koumiss is made in the early summer by 
pouring fresh milk into smoked leather bottles or sabas, to which 
is added a little sour cow's milk or old dry koumiss ferment. The 
skins are kept at a temperature about equal to the body heat and 
are frequently shaken for thorough mixing, and fermentation is 
allowed to proceed for three or four days. 

In the United States koumiss is manufactured from cow's milk 
by the addition of some artificial ferment. Such home-made koumiss 
may be prepared as follows : 

Take 2 teaspoonfuls of wheat-flour dough, 2 tablespoonfuls of 
millet flour, 1 tablespoonful of honey, 1 tablespoonful of beer yeast. 
Mix into a thin paste with milk. Place in a warm place to ferment. 
When fermented, put into a linen bag and hang in a covered jar with 
sixteen pounds of fresh milk. Let stand for twenty-four hours, or 
until the milk becomes acid, at a temperature of 86° to 90 F. Skim, 
decant, agitate for an hour, bottle and cork tightly, protecting the 
corks with wire fastenings. Keep in a refrigerator. Absolute clean- 
liness must be insisted upon throughout all the various manipula- 
tions; otherwise different forms of fermentation will result (Stange). 

Properties. — Koumiss when shaken froths readily. It has, when 
fresh, a slightly sour odour, agreeable bitter taste, and acid reaction. 
The specific gravity is 1.018 to 1.029. During fermentation alcohol 
is developed from the milk sugar, which forms lactic acid and glu : 
cose, the latter making alcohol and carbonic acid. The alcohol may 
reach 2.5 per cent, but koumiss made from cow's milk may not con- 
tain above 1 per cent. Koumiss becomes stronger in both taste and 
smell after keeping for a day or two. It is highly sensitive to tem- 
perature changes, and easily putrefies. 

There are two varieties of koumiss prepared which differ in de- 
gree of fermentation and in their exhilarating and intoxicating 
properties. The lighter form contains less alcohol than the heavier, 
in which fermentation has proceeded further. 

The following analysis by Stange illustrates the changes in com- 
position which koumiss undergoes by prolonged fermentation : 



Table of the Percentage Composition of the Several Strengths of Koumiss 

(Stange) 





Mare's 
milk. 


KOUMISS— DURATION 


OF FERMENTATION. 




6 hours. 


18 hours. 


30 hours. 


4 days. 




51 

23 
19 

5 


3-8 
18.5 

3-9 

18.8 
22.5 
18.9 

4-5 


6.0 
19-5 

5-6 
16.3 
22.6 
20.0 

4.0 


70 

30.0 

6.4 

20.0 

IQ.O 

4.0 


II .O 


Alcohol 


30.0 
6.4 


Lactic acid 




Albumin 




Fat 


I9;0 

4.0 


Salts 





£2 FOODS AND FOOD PREPARATIONS 

The casein, after being first precipitated, is converted into pep- 
tones and an acid albumin. It should be remembered that the com- 
position of koumiss is always changing unless the fermentation be 
constantly held in check by extreme cold. Koumiss grows more 
and more acid and keeps but a short time when exposed to the 
air. If spoiled, it may produce severe symptoms of ptomaine 
poisoning. 

Koumiss is prepared in tablet form under the name of koumysgen, 
each tablet, it is claimed, containing 30 per cent of soluble casein. 
The tablets keep indefinitely in air-tight bottles, and when dissolved 
in water form a cooling effervescing food, possessing similar proper- 
ties with koumiss, and it is cheaper. It is doubtful, however, whether 
any preparation can be made to reproduce all the peculiarities and 
advantages of fresh koumiss, which is so variable and delicate a 
-substance. 

Koumiss Cure. — The " koumiss cure " consists in taking a large 
quantity of koumiss — in some cases 15 to 20 tumblerfuls a day — in 
combination with nourishing albuminous food. If perfectly fresh it 
may be drunk warm, but if it is to be kept for some time it is better 
to drink it cold. Koumiss which is either too fresh or which has not 
been kept clean may cause flatulency, colic, and diarrhoea, but old 
koumiss has the opposite effect upon the bowels, and, like milk, gives 
rise to constipation. Koumiss resembles whey in being strongly diu- 
retic and diaphoretic, and thus relieves the mucous membranes of 
congestion. It also alleviates thirst, strengthens the action of the 
heart, and improves the vascular tone, general nutrition, and com- 
plexion. The solids of the urine are increased during its use. The 
use of koumiss is said to be contraindicated in renal and vascular 
diseases, gout, plethora, and chronic constipation. 

At first but two or three tumblerfuls of koumiss are allowed daily 
until the stomach becomes accustomed to it ; then patients are made 
to drink a glass at frequent intervals during the day and sometimes 
as often as once every half hour. Some patients can digest very 
large quantities of koumiss, and as much as to litres have been taken 
in twenty-four hours, but less is used now than formerly; patients 
do not often exceed 6 or 8 litres a day, and for the average from 2 
to 4 is quite enough. Tender beef and abundant butter, cream, and 
a moderate supply of bread compose the basis of the other foods 
allowed. Sweets, salads, and other beverages than koumiss are for- 
bidden. 

The treatment should be commenced slowly in order to accustom 
the digestive system to the fermented drink, which otherwise may 
excite diarrhoea. The latter accident may be counteracted by lime 
water or some simple remedy, such as bismuth. 

The koumiss prepared from milk in the United States does not 
seem to possess the peculiar properties and extraordinary nutritive 



ANIMAL FOODS 83 

value which is attributed to it when made from mare's milk in Rus- 
sia, on which patients are said to gain rapidly in weight. In various 
Russian cities there are special institutions designed for carrying out 
the koumiss cure, and which are supplied with the genuine article 
from the steppes. 

Special koumiss cures are not in vogue in this country, but in 
southeastern Russia there are several establishments, notably in the 
districts of Orenberg and Samara, where patients go for treatment 
during several months in summer, and derive great improvement. 
Like other popular ' k cure " resorts in Europe, these establishments 
furnish the patient with suitable light and varied amusement during 
the progress of his treatment, which is highly beneficial, by diverting 
the mind and relieving an otherwise monotonous regime. While un- 
dergoing the koumiss cure, patients are made to live outdoors as 
much as possible, and tent life with free exercise is no doubt a very 
important adjunct to the treatment when it can be obtained. The 
climate is both hot and dry, and the elevation is high. 

The koumiss cure is particularly available for chronic catarrh of 
the respiratory and alimentary canal, and in the first stage of pul- 
monary tuberculosis. It is also especially recommended for general 
debility resulting from pronounced anaemia, and for various diatheses, 
such as scrofula, rhachitis, etc. The large percentage of carbonic 
acid which is produced by koumiss fermentation, together with the 
alcohol present, acts as a stimulant to the gastric mucous membrane, 
favourably affects digestion, and lessens irritability of the stomach. 
Among other effects produced by the use of koumiss may be men- 
tioned occasional drowsiness and lassitude. This food is also said 
to possess some aphrodisiac influence. 

Kefir. — Kefir is another form of fermented milk which resembles 
koumiss, and has long been used in the Caucasus. 

Kefir contains three varieties of ferments which produce com- 
plex fermentation processes resulting in the formation of alcohol, 
lactic acid, modified albumins, and peptones. The casein of milk is 
in great part digested by them, and the portion which remains is 
precipitated in flocculi instead of heavy curds. The milk sugar is 
almost completely converted into alcohol and carbonic-acid gas, 
which bubbles to the surface. Kefir has a sour taste, due to the 
organic acids which it contains. 

Zoolak. — Zoolak, formerly called Matzoon, is a form of milk in 
which lactic-acid fermentation has been produced by a ferment much 
used in Syria. It has the same general properties and effects with 
koumiss, and is an excellent invalid food. 

Lactone is an unfermented milk preparation freed from fat, steril- 
ised and rendered effervescing by means of carbonic-acid gas. Ac- 
cording to the late Charles Rice, chemist of Bellevue Hospital, 100 
parts by weight contain : 



84 FOODS AND FOOD PREPARATIONS 

Fat o. 10 

Casein and albumin 5-37 

Milk sugar 5 . 80 

Salts 1 . 20 

Water 87 . 53 

100.00 

IV. Methods of Sterilisation and Preservation 

1. Sterilisation. 2. Pasteurisation. 3. " Humanised milk." 4. 
Modified milk. Milk laboratories. 

1. Sterilised Milk. — The sterilisation of milk is accomplished by 
heating it up to the boiling point, 212 F. In a vacuum this may be 
accomplished by a temperature a few degrees lower. 

The construction of steam sterilisers for milk, beef tea, or other 
foods is based upon a very simple plan. It is a familiar fact that 
the steam which rises from water heated in a tin or copper can con- 
denses in drops on the lid, and this condensed vapour drips back 
along the sides of the can. If the lid is raised a little and is made 
somewhat larger than the can, the condensed steam will drip down 
on the outside of the can instead of the inside. If a second larger 
can be inverted like a hood or jacket over the first, the steam con- 
densed between the two cans drips back and may be made to rejoin 
the water from which it started. In this way a kind of perpetual 
motion is kept up so long as a flame is applied beneath the water to 
vapourise it. Bottles containing the food to be sterilised are sus- 
pended in racks in the upper part of the inner chamber in the at- 
mosphere of steam, and their contents soon acquire the temperature 
of boiling water, 212 F. 

Siebert removes the grosser impurities of milk by placing it on a 
thick layer of sterilised absorbent cotton in a clean glass funnel. A 
quart of milk will pass through in ten or fiteen minutes. 

Mobrun preserves milk for six months by warming it in a tin re- 
ceptacle, the only opening of which is through a lead tube. The 
milk is rendered sterile by the heat, and all air is driven out through 
the tube, which is then compressed and soldered. 

The taste of sterilised milk is peculiar and resembles that of 
boiled milk. If put in bottles which have been sterilised by boiling 
water or steam, by stopping them with pledgets of absorbent cotton 
which have been baked, the milk will keep fresh for a number of days 
— long enough to be carried upon a voyage to England or across the 
continent. 

Milk drawn by clean hands fresh from the cow into bottles which 
have been sterilised by boiling water is germ-free, and need not be 
further treated ; but the milk usually served in cities from large cans 
which have been hawked about the streets has passed through sev- 
eral receptacles and been exposed to the air. (See Milk Adultera- 



ANIMAL FOODS 85 

tion and Impurities, p. 61.) It is better always to keep milk germ- 
free, but it is absolutely necessary to do so in summer if it is to be 
fed to infants. In 1899 sterilising apparatus was introduced at the 
Children's Hospital, Randall's Island, New York city, with the imme- 
diate effect of reducing the annual infant death rate from 44.36 to 
19.86. It is often advisable to sterilise milk for feeding to typhoid- 
fever patients and others in whom asepsis of the alimentary canal is 
of paramount importance. If milk be too long sterilised it becomes 
of a brownish hue, owing to the conversion of its lactose into 
caramel. 

It is suggested by Barlow that prolonged sterilisation of milk 
may lessen its antiscorbutic powers for young infants, but scurvy in 
infants is due also to other causes, such as feeding with artificial 
foods, and prolonged exclusive plain milk diet for adults reduces 
them to a condition resembling scurvy. (See Typhoid Fever, Milk 
Diet.) 

According to Leeds, the following alterations are produced in 
milk by sterilisation at 212 F. : 

1. The amylolytic ferment is destroyed. 

2. The casein coagulates less readily by rennin. 

3. The digestibility of casein by the gastric and pancreatic juices 
is somewhat retarded. 

4. The fat is less promptly absorbed than normally from the in- 
testine. 

5. If the heating is continued for some time, the milk sugar is de- 
stroyed. 

The mineral salts of milk are also dissociated in some degree 
from their organic compounds. 

In churning sterilised milk, butter forms more slowly than 
from raw milk, a period two or three times longer being required. 
Hirsch attributes this to toughening of the albuminoid envelopes 
(of lactalbumin) of the fat globules, which is produced by the 
heat. 

For these several reasons an infant to be fully nourished on ster- 
ilised milk requires more of it than of raw milk. 

Practically, in normal stomachs of either infants or adults these 
changes are not sufficiently pronounced to seriously interfere with 
the digestibility of the milk, but dyspeptic and catarrhal conditions 
of the stomach, especially in infants, make it highly sensitive to very 
slight modifications in the composition and reaction of milk. In 
quite recent years it has been proved that the method of Pasteurisa- 
tion is preferable to sterilisation, and it is now much more in vogue 
except where milk has to be prepared to keep for several days. 
(See 2. Pasteurised Milk, p. 86.) 

The directions for predigestion combined with sterilisation of 
milk at the Philadelphia Hospital are thus given by Hirst : 



86 FOODS AND FOOD PREPARATIONS 

" I. Have the nursing bottles prepared clean every morning. 

" 2. Take cream, five ounces ; milk, two and a half ounces. 

" 3. Put in skillet ; add pancreatin powder (pancreatin, two and a 
half grains ; sodium bicarbonate, five grains) ; heat over alcohol flame 
for six minutes ; stir and sip constantly ; do not overheat. 

" 4. Of this mixture put in each bottle six drachms (for a two- 
ounce bottle). Use funnel. 

" 5. Add to each bottle ten drachms of sugar solution. (Make 
sugar solution by dissolving an ounce of sugar of milk (one powder) 
in a pint of warm water.) 

" 6. Stopper the mouth of each bottle with dry baked cotton and 
sterilise for twenty minutes. 

" 7. Set aside to cool. 

" 8. Before use put bottle in warming cup ; apply nipple imme- 
diately before giving it to infant." 

The alimentary canal of the newborn infant is sterile — it con- 
tains no bacteria — but after the first few passages of meconium two 
species of bacilli and one of micrococci are found (Escherich, Bes- 
lau), which disappear with the meconium. There are but two species 
of bacteria found in the stools of healthy nursing infants, the Bac- 
terium lactis aerogenes, obtained from the ileum below the duodenum, 
and Bacillus coli communis, from the colon. 

In diarrhceal conditions other bacteria, to the number of forty 
species, have been found (Booker). Their action in different dis- 
eases is not yet differentiated, but they are associated more or less 
directly with malfermentation and the formation within the intes- 
tines of gases and irritable or poisonous products. Many of these 
species thrive and are reproduced in hot weather outside the body 
in milk, in the atmosphere, and upon diapers and utensils. This 
explains the importance of absolute aseptic cleanliness in every- 
thing that pertains to the nursing and feeding of infants — cleanliness 
of the breasts and nipples, of the nurse's hands, of all receptacles for 
milk or other foods, of the child's body, and prompt removal and 
disinfection of soiled diapers or clothing. 

Most of these bacteria grow best in milk, and the diarrhoeal dis- 
eases which are caused by and associated with triem are absolutely 
preventable when the methods are understood of avoiding milk in- 
fection, and of sterilisation when it is infected. Vaughan says with 
proper emphasis : "If parents were willing to pay for wholesome un- 
infected milk half the fancy price which they readily give for some 
prepared baby food, their children would be better nourished and 
disease among them would be less frequent." 

2. Pasteurised Milk. — Pasteurised milk is similarly prepared to 
sterilised milk, and is, in fact, sterile, but the temperature is only 
raised for twenty minutes to 167 F., instead of the boiling point, 
212 F. It is somewhat more easily digested than sterilised milk, 



ANIMAL FOODS 8/ 

but it does not keep so long and spoils in one or two days. It has 
the advantage of tasting more like fresh milk. 

Cleansing Milk Bottles. — Both sterilised and Pasteurised milk 
should be warmed by placing the milk bottles in warm water without 
opening them. If the bottles are to be used again they should be 
rinsed and left standing full of water to which one or two teaspoon- 
fuls of borax or soda have been added. Before rilling with milk 
they should be washed with a fresh swab and hot soapsuds, rinsed 
again with boiled water, and kept for at least twenty minutes in boil- 
ing water, or they may be placed in a steam sterilising apparatus 
under pressure. Rubber nipples for infants' bottles must be kept in 
borax water and rinsed several times daily. Rubber tubing should 
be discarded. 

The heat of Pasteurisation is sufficient to destroy all bacteria 
likely to be present without so much alteration of the properties of 
the milk as occurs in sterilisation. 

Different experimenters have shown that the tubercle bacillus in 
milk is destroyed by a ten-minutes' exposure at 167 F., whereas the 
germs of cholera, pneumonia, and typhoid fever may be quickly de- 
stroyed in milk at 140 F. (Van Geuns). 

Freeman has shown by experiments that — 

" 1. Pasteurisation of milk at 75 C. (167 F.) affords a safeguard 
against the deleterious effects of any bacteria which it may contain, 
without interfering with its nutritive qualities. 

" Pasteurisation at about 75 C. (167 F.) destroys efficiently the 
germs of cholera, typhoid fever, diphtheria, and tuberculosis as well 
as the Streptococcus pyogenes, the Staphylococcus pyogenes aureus, and 
the Bacillus coli communis!' 

The Bacillus acidi lactici is also prevented from acting after ex- 
posure to a temperature of 160 F. 

It is found that by immersing bottles of milk in water which has 
just been removed, while boiling, from the fire, a fairly uniform 
temperature of 167 F. is obtained. Naturally, the relation between 
the volume of water used and the quantity of milk must be properly 
balanced, and various forms of graduated receptacles are sold which 
make the process very easy and simple. 

A graduated covered pail, into which the boiling water is poured, 
is fitted with a rack to submerge enough bottles of milk for the day's 
use, and this is all that is necessary. After half an hour's exposure 
to the heat the milk, as in the case of sterilised or pancreatinised 
milk, is set in a refrigerator until ready for use. 

Under some conditions both sterilised and Pasteurised milk form 
smaller curds than raw milk, although this is not the case with the 
coagulse formed by gastric juice (Freeman). 

The poor in New York city are now supplied with cheap Pasteur- 
ised milk through the philanthropy of Mr. Nathan Straus, who in 



88 FOODS AND FOOD PREPARATIONS 

1893 opened the first milk depot for dispensing pure milk and Pas- 
teurised milk, at a cost of but one and a half cent for an eight-ounce 
bottle. A sterilised nipple is also furnished with each bottle. The 
bottles have sloping necks, to facilitate cleansing, and spheroidal bot- 
toms to prevent them from being left standing about uncorked. In 
an account of this system by Dr. Freeman he states that : 

" In addition to Pasteurised ordinary milk and Pasteurised modi- 
fied milk, a Pasteurised milk diluted with barley water and sweet- 
ened with cane sugar, and containing also table salt, has been intro- 
duced at the suggestion of Dr. Jacobi. The formula used is : 

Table salt ± oz. 

White cane sugar 10 oz. 

Milk 1 gal. 

Water 1 gal. 

" This barley milk will be dispensed in six-ounce bottles." 

3. Humanised Milk. — Humanised milk is really Pasteurised milk 
but with a permanent alkaline reaction and partial predigestion. 
Leeds claims the credit for the origin of the idea of this form of milk, 
and his formula is : 

Milk £ pint. 

Water £ " 

Cream 4 tablespoonfuls. 

Peptogenic milk powder 1 large measure. 

Heat to 160' to 170 F. for ten to twenty minutes. 

Instead of cream, some other' form of fat may be added for invalids, 
such as olive or cod-liver oil or cacao butter. 

The name " humanised milk " is applied somewhat indefinitely 
to various preparations of cow's milk in which the attempt is made 
to approach more nearly the composition of human milk by lessen- 
ing the casein and increasing the sugar and fat. These prepara- 
tions are partially predigested, but the pancreatinisation is stopped 
before it has proceeded far, so that the infant stomach shall still 
have some work to do. 

Another good mixture designed to resemble human milk is that 
of Meigs : 

Cream 2 tablespoonfuls. 

Milk 1 tablespoonful. 

Lime water 2 tablespoonfuls. 

Water 3 

Milk sugar . . | teaspoonful. 

4. Modified Milk. Milk Laboratories. — The establishment of milk 
laboratories having in view the object of modifying cow's milk for 
infant and invalid feeding has demonstrated the practical value of 
this work. Such milk is now called " modified milk." The first 



PLATE I. 



Centrifugal 
Separator. 



Sterilizer. 
Capacity 500 pints. 




Care of Modifying Materials. Aseptic Precautions. 




Milk Room and Coolers for 
modifying materials. 



Special Sterilizers for 
returned packages. 



MILK LABORATORY (INTERIOR). 
(From Paediatrics, by T. M. Rotch, M. D.) 






ANIMAL FOODS 89 

laboratory founded in Boston during iSo^-'o/}, upon the sugges- 
tions of Dr. Rotch, completely fed about twelve hundred infants and 
was patronised by more than one hundred and fifty physicians in its 
first year. Many similar laboratories have subsequently been estab- 
lished. The milk is derived from carefully selected animals kept 
at farms where their food, stabling, drinking water, and pasture are 
under the scientific supervision of a veterinary surgeon. 

It is now generally acceded that infants thrive better in the long 
run upon mixed milk derived from several cows than by the exclusive 
use of milk from a single animal, which is more likely to vary with 
the condition of the cow at different times ; but it is possible to avoid 
all variation in milk and keep it at a standard which can be graded to 
correspond with the increasing age of the infant, by the employ- 
ment of proper means in the milk laboratories, where milk can be 
prepared with its ingredients mixed with the accuracy of a medicinal 
prescription, while its freshness and purity are absolutely insured. 
If desired also, the milk may be predigested in the laboratory, and 
sweet whey and other materials derived from fresh milk may be 
obtained there. 

Physicians are furnished with blank forms upon which they can 
definitely prescribe the composition of the milk which they wish to 
order for any individual case. A sample prescription form from the 
Briarcliff Laboratory is herewith appended : 





Per cent. 




Remarks. 


Fat 

Milk sugar 

Proteids 

Mineral matter 






Number of 
feedings ? 

Amount at 

each feeding? 

Infant's age ? 


Total solids 
Water 






IOO.OO 


Infant's weight ? 



Alkalinity. 

Raw. Pasteurised ° F. Sterilised 

Ordered for 

Date. Signature. 



M. D. 



" If the physician does not care to mention the especial per- 
centage, he can ask for percentages which will correspond to the 
analysis of human milk, and he can then vary any or all of these 
percentages later, according to the need of the especial infant pre- 
scribed for " (Rotch). 

In order to prepare modified milk by Rotch's method it is neces- 
sary to have: I. Pure cream containing the fat. 2. Pure milk con- 






90 FOODS AND FOOD PREPARATIONS 

taining the albuminoids and no fat. 3. Distilled water. 4. A 20 
per-cent solution of milk sugar made fresh daily with distilled water 
5. Lime water. 

The milk and cream are separated completely by an apparatus 
made to revolve 6,800 times per minute, so that they may be recom 
bined in any desired proportion. The resulting cream has an aver- 
age of 35 per cent of fat, but the percentage may vary between 45 anc 
18, hence analysis should be made whenever accuracy is essential 
After separation of the cream the milk is modified according to th( 
formula prescribed for each case, and Pasteurised. 

Rotch gives the following sample prescriptions for modified mill 
to be sent by the physician to the laboratory : 

5 (1) A girl 6 years old : duodenal jaundice. 

Fat o . 50 

Milk sugar 6.00 

Albuminoids 4 . 00 

Give 4 ounces every two hours. 
Send 12 tubes, each 4 ounces ; lime water, ^V- 
Note. — This patient made a rapid recovery. No medicines were given. 

5 (2) A boy 6 weeks old : healthy. 

Fat 3.00 

Milk sugar 7 . 00 

Albuminoids 1 . 50 

Send 12 tubes, each 2 ounces. 
Lime water, ^$. 
Pasteurise at 167 F. 

5 (3) A boy 6 months old : healthy. 

Fat 4 . 00 

Milk sugar 7.00 

Albuminoids 2 . 00 

Send 8 tubes, each 6 ounces. 

Lime water, yq. 

Pasteurise at 167°. 

1$ (4) A girl 4 months old : albuminoid digestion weak. 

Fat 4.00 

Milk sugar 7 . 00 

Albuminoids 0.75 

Send 8 tubes, each 4 ounces. 

Lime water, - 2 V 

Pasteurise at 167 . 

3 (5) A boy 6 months old : sugar digestion weak. 

Fat 3 . 00 

Milk sugar 4.00 

Albuminoids 2 . 00 

Send 8 tubes, each 6 ounces. 

Lime water, ^ ~- 

Pasteurise at 167 . 



ANIMAL FOODS 91 

I£ (6) A girl 4 months old : summer diarrhoea. Food has to be sent out of town 
by express. 

Fat 2 . 00 

. Milk sugar 5 . 00 

Albuminoids 1 . 00 

Send 20 tubes, each 1 ounce and I drachm. 
At time of each feeding add lime water, 3 drachms. 
Sterilise at 212 . 
Note. — In this case the diarrhoea had not been sufficiently studied to determine 
whether it was putrefactive or fermentative, so that a safe general prescription was 
sent to begin with. The lime water had to be introduced at each feeding on 
account of the 212 sterilisation necessitated by the hot weather and the distance 
to be sent. 

An ingenious measuring glass is recommended by L. Emmet 
Holt for the home modifying of milk. The glass, which is sold under 
the name of the " Materna " (Estraus), holds sixteen ounces and has 
seven panelled sides. On one side is graduated the quantity of 
separate ingredients of normal milk and on each of the other 
panels is graduated the ratio of ingredients of milk modified 
to suit a certain age of infancy. Milk sugar is placed in the 
bottom of the glass, water is added to a marked level, then, in 
turn, lime water, cream, and milk. The formulas given are the 
following (Holt) : 



Formula 


I 


2 


3 


4 


5 




6 


Fat 


■2% 


2i% 


3% 


$J> 


A% 




zk% 


Sugar 


6% 


6% 


6% 


7% 


7% 


For this Formula 


34* 


ProteiJs 


0,6% 


o,8# 


i% 


itf 


■2.% 


6 see special 

instructions 

below. 


2# 




3d day to 


2d wk. to 


6th wk. to 


nth wk. 


5th mo. to 


9th mo. to 




14th day. 


6th wk. 


nth wk. 


to 5th mo. 


9th month 


12th mo. 


Milk parts 


if 


2 


4* 


6 Milk parts 


94 


Cream 


T JL 


If 


2 


2 


2 Cream 


1 


Lime water " 






1 


1 


f Barley gruel " 


5* 


Water 


I2| 


Hi 


Hi 


8f 


7\ Gran, sugar " 


i 


Milk sugar " 


1 




I 


1 


ii 







Directions for Formula 6 

Sugar. — In formula 6 granulated sugar should be used instead of milk sugar. 
Introduce the same into the vessel to the line thus marked. 

Barley Gruel. — In formula 6 barley gruel should be used instead of water and 
filled to the line thus marked. Barley gruel should be prepared as follows : 

To one tablespoonful of pearl barley (after soaking several hours) add one pint of 
water, a pinch of salt, and boil for five or six hours, adding water as it boils away. 
Strain through muslin. Or add : 

One rounded tablespoonful of Robinson's barley flour ; rub up with cold water, and 
add to one pint of boiling water; cook fifteen minutes, stirring, and strain if lumpy. 



According to Rotch, " certain breeds of cows are better than 
others for copying human milks." 



92 FOODS AND FOOD PREPARATIONS 

List of Breeds best Adapted for Modified Milk, with Analyses (Rotch) 





Fat. 


Milk 

sugar. 


Albumi- 
noids. 


Mineral 
matter. 


Total solids. 


Water. 


Durham 


Per cent. 
4.O4 
4.O9 
3-89 

2.88 
4.01 
3-69 


Per cent. 
4-34 
4.32 
4.4I 

4-33 
4-36 

4-35 


Per cent. 
4.17 
4.04 
4.OI 

3-99 
4.06 
4.O9 


Per cent. 
0.73 
O.76 

0.73 
O.74 
O.74 

0-73 


Per cent. 
13.28 
13.21 
I3.O4 
II.94 
13.17 

12.86 


Per cent. 
86.72 
86.79 
86.96 

88. 06 
86 83 
87.14 


Devon 


Ayrshire 


Holstein-Friesian 

American grades 

Common natives 



The Jersey cow may yield more than 6 per cent of fat. 

" The time of the year, the food and care given to the cattle, the 
month of lactation, and manner of milking — all exert such a profound 
influence, that the fat mav be lower than 2.5 per cent or as high as 
8 per cent " (C. E. Woodruff, U. S. A.). 

Many so-called " milk foods " are sold for infant and invalid 
use. Their object is to furnish a ready-made substitute for fresh 
milk, which is easy of preparation even by an unintelligent nurse. 
Generally speaking, the continued use of such foods, especially for 
young growing infants, is to be condemned whenever fresh milk is 
obtainable, but in travelling at sea, or wherever good milk is not 
procurable, and in other emergencies, they may be resorted to with 
advantage, until more favourable conditions obtain. Analyses of 
some of the best known of these foods are appended below, and 
compared with the composition of mother's milk. 



Name of Food. 



Ideal mother's milk. 

Malted milk 

Nestle's milk food.. 
Carnrick's soluble food 
Lactopreparata. . . 
Lactated food. . . . 

Malted milk 

Nestle's milk food. 
Carnrick's soluble food 
Lactated food.. . . , 
Carnrick's soluble food Stutzer. 
Lactated food " 



Analysed 
by. 



ISr,*-. 



Rach. 



Leeds. 



4.0046. 
3.2746, 
4.5137. 
'5-9330. 

15.80,63. 
J7.8028. 
I2.18 50. 
4.7238. 
|3-42;27. 
J7.7629. 
5.1728. 
|6.52 25. 



Dex- 
trin. 



Starch. 



io.33 35 
16.09 5. 
'40. 

137. 

9-35 36. 

4i- 

52. 



Fat. 



Albu- 
mi- 
noids. 



23-39 
6.78 

5-37 
2.96 

I2.35|i4 
1.82 13 
3.30 16 
1.91 

7-45 
1.64I11 

5-53JI6 
2.19 9 



10 



Ash. 



2.44 
3-90 

1-59 
3.02 
3-66 
2-77 
3.13 

i-59 
4.42 
2.61 
3.00 
2.26 



Solubility in 
water. 



Very soluble. 
Insoluble. 



Soluble. 
Soluble. 



Lacto preparata is a preparation of pure selected milk from which 
the cream has been removed by centrifugal force, and for it is sub- 
stituted cacao butter, which keeps better and is quite nutritious. 
Lime water is then added and the mixture is sterilised, evaporated, 
powdered, and sealed hermetically in cans. 

The other foods of the list above given all contain considerable 
starch, and will therefore be described in the section upon Prepared 
Farinaceous Foods. 



ANIMAL FOODS 93 

Gustav Gaertner's Mother Milk, according to Theodore Escherich, 
contains in percentages, albumin, 1.76; cream, 3.0 to 3.5; lactose, 
2.5 ; ash, 0.35, thus closely approximating the composition of human 
milk, except that it has less sugar. The fresh cow's milk is mixed 
with sterilised water and placed in a centrifugal separator to re- 
move impurities and separate the superfluous casein, without remov- 
ing the fat, to form proportions more closely resembling those of 
human milk. The casein curds of this prepared milk are much more 
flocculent than those of the original cow's milk. By this process the 
milk also loses a half of the original salts and sugar, but the latter is 
easily added again when desired. The milk is sealed hermetically 
in tin cans, in which it keeps fresh for a year or two. 

Milk Derivatives 

The principal foods derived from milk which are in common use 
are : 

1. Condensed milk. 2. Cream. 3. Butter. 4. Buttermilk. 5. 
Cheese. 6. Whey. 

1. Condensed Milk. — Condensed milk is prepared by slowly 
evaporating the water of milk by moderate heat in vacuo to the con- 
sistence of honey. There are two varieties : the " plain," which is 
condensed to about one fourth of its bulk and superheated, and to 
which little or no sugar is added ; a stronger, more condensed sort, 
with which cane sugar is mixed in excess. Such milk yields from 
39 to 48 per cent of sugar among its solid ingredients, but some- 
times as much as 75 per cent is added. A good deal of the Swiss 
condensed milk sold in market, as well as that made in this country, 
contains 40 per cent of sugar. 

The sugar prevents fermentation and decomposition, and when 
condensed milk is put up while hot in hermetically sealed tin cans it 
will keep fresh for years. It will even remain fresh for several days 
after a can is opened. It is soluble in water added to any degree of 
dilution. Condensed milk is largely used for the nourishment of 
infants, especially among the poorer classes. They thrive upon it 
for a time, occasionally even better than on raw milk, and it makes 
them fat, owing to the extra sugar which it contains. It does not 
constipate, and may be even slightly laxative. But although such 
babies may appear robust, their flesh is not firm, they develop poorly, 
are unable to resist disease, and become rhachitic. 

Condensed milk should be diluted ten times for a child a month 
or two old, and cream should be added in liberal proportion. 

The formula recommended by Starr is : 

Condensed milk 3 j ", 

Cream f § ss. ; 

Hot water f | ijss. 



94 FOODS AND FOOD PREPARATIONS 

This milk, when diluted, speedily undergoes lactic-acid fermen- 
tation and causes diarrhoea and thrush. 

Condensed milk has been used with advantage in the treatment 
of dysentery (Hiibner) and as a prophylactic against scurvy. It is 
serviceable on long voyages and expeditions where fresh milk can- 
not be obtained for use with tea, coffee, etc. 

Unsweetened condensed milk made of fresh Swiss Alpine milk, 
and sold under various brands in this country, is prepared by evapo- 
ration by heat sufficiently strong to render the milk aseptic, so that 
no preservative materials are added. The water is reduced from 
the normal standard of 88 per cent to about 61 per cent. It is open 
to the same objections as the use of sterilised milk (see Sterilised 
Milk, p. 85), but it is better for infants than those forms of condensed 
milk in which preservation is secured by the addition of too large a 
proportion of cane sugar. An analysis of one brand of this milk 
is given by Professor Goodfellow, as follows : 

Water. 61.3 

Casein 9.1 

Albumin .' 1.5 

Fat II. 7 

Lactose 14.3 

Salts (mineral matter) 2.1 

100. o 

Milk may be preserved for some time in hermetically sealed cans 
or bottles without previous condensation, but a separation of the 
cream eventually takes place, and butter forms in the can. 

2. Cream. — Cream is the fat of milk, which, by virtue of its light 
specific gravity, floats to the top of vessels in which milk is allowed 
to stand for some hours. The globules collect in a yellow layer of 
varying thickness. The rise of the cream is retarded by coagulation, 
but favoured by a cool temperature and by richness of the milk. 
Cream is best obtained by placing the milk in broad, shallow pans. 
The fatty material is complex, and consists of glycerides of stearic, 
palmitic, myristic, oleic, butyric, and soluble fatty acids. Churning 
the milk causes the globules of fat to coalesce in small lumps and 
form butter. It is a popular fallacy that a little warm water added 
to milk increases the cream formation. It lessens the specific 
gravity of the milk and hastens the floating of the globules, but the 
ultimate quantity of cream is not affected. If the cream falls below 
5 per cent of the volume of milk, the milk has been watered. The 
normal average quantity of cream is over 8 or 9 per cent, but 
there may be above 20 per cent. The breed, age, and feed of 
the cow have a marked influence upon the quantity of cream. 
Alderney milk is rich in fat ; longhorns give proportionately more 
casein. 



ANIMAL FOODS 95 

The milk which comes from the cow towards the end of milking 
contains more cream than that which is first drawn. This fact should 
be borne in mind by those who use milk drawn direct from the cow 
into separate small vessels. Afternoon milk is richer than morning- 
milk in both protein and fat. 

Centrifugal or Separator Cream. — Cream may be separated from 
milk by centrifugal force. A small and large drum are placed one 
within the other, leaving a space of a few inches between. The 
inner drum is made of porous material. It is filled with milk and 
set in rapid revolution. The lighter cream remains in the inner 
drum, while the other ingredients are thrown with such violence 
against the porous wall that they are forced through it into the outer 
drum. It is claimed that the cream is more thoroughly separated 
in this manner than when it is allowed to rise on standing, and the 
process is far more rapid. Separator cream does not remain fresh 
so long as that obtained by natural means, for it is separated at a 
temperature favourable to the growth of bacteria. 

Condensed or evaporated cream, which is offered in market, con- 
sists of about one fourth cream and three fourths other ingredients 
of milk, the whole milk having been evaporated by machinery. It 
is therefore a natural product, easily digestible on account of the 
dilution of the cream with the nitrogenous ingredients of the milk, 
and, unlike much condensed milk, it is not artificially sweetened. It 
is sometimes mixed with malt extract. 

Clotted or Devonshire cream is skimmed from heated milk, so that 
the albumin is coagulated with it. It is warmed over a slow fire not 
above 150 F. Fothergill wrote, " Devonshire cream is delicious 
with preserved ginger, while cream and maraschino form a nutritive 
drink for the affluent consumptive." 

In cooking, suet is sometimes added to replace cream and impart 
additional colour and flavour to milk. 

Cream is one of the most wholesome and agreeable forms of fat. 
It is often eaten too rich, and may disagree on that account, whereas, 
diluted with an equal bulk of water or of lime water, it is well borne. 
It is an excellent substitute for cod-liver oil in tuberculosis, for, al- 
though not quite so digestible, most persons prefer to take it. It is 
an excellent food in tuberculosis and long-continued suppurative dis- 
eases, such as empyema or tubercular joint diseases. It should be 
avoided in flatulent dyspepsia, in most forms of gastric disease, 
obesity, and gallstones. 

It is useful as a substitute for milk when diarrhoea or maras- 
mus, etc., occurs in infants. It should be considerably diluted when 
so given. 

The addition of strong liquors to cream lessens its digestibility 
just as heat does, for alcohol coagulates and toughens the proteid 
envelopes of the fat globules. 



gb FOODS AND FOOD PREPARATIONS 

Ice cream, when very simply made, is nutritious, and may be 
allowed many patients. It is soothing to inflamed throats and en- 
joyed by convalescents from fevers, and children who object to milk 
will often take it. It should be eaten very slowly, so that it may 
become well warmed in its passage to the stomach ; otherwise it 
retards digestion. 

3. Butter. — Butter is made from cream by the mechanical rup- 
ture of the albuminous envelopes which inclose the fat globules. 
The globules then adhere together in small masses. The rupture 
is accomplished by churning, and after the butter is of sufficient 
density, salt in small proportion is added, and the butter is " worked " 
over with a spatula and frequently washed. 

An average sample of good butter contains: Water, 11.83 P er 
cent; fat, 82.76 per cent; casein, 0.18 per cent; milk salt, 5.22 per 
cent (Konig). The fats comprise six neutral varieties, four of which, 
being volatile, give to it taste and odour (Chevreu). 

The quantity of casein in butter can be roughly estimated by 
melting a specimen in a test tube, when the casein forms a layer at 
the bottom. 

Butter should not have less than 0.5 to 2 per cent nor more 
than 8 per cent of salt added. 

Perfectly fresh butter made without salt is comparatively taste- 
less and keeps poorly. The decomposition of its nitrogenous ma- 
terial liberates a ferment which separates fatty acids and glycerin. 

Butter is adulterated by dealers by beating it up with water and 
by adding other fats, especially suet and oleomargarine. The sophis- 
tication with water is easily detected by melting, when the sample 
separates into two layers. 

Fresh butter if kept too long, especially in hot weather, soon 
becomes rancid, bitter, and unwholesome. 

Butter which contains too much water and too many ingredients 
other than the fat has not been sufficiently " worked," and is also 
likely to become rancid and cause violent gastric derangement. 
Very thorough washing of butter when first made will remove much 
of its proteid substance and tend to prevent its fermentation ; and 
fresh butter which has once become rancid may be rendered less so 
by melting and shaking it in boiling water which is several times re- 
newed and then pouring it into ice-cold water. It is then called 
" smalt." The addition of salt to butter in the strength of twenty to 
twenty-five grammes per kilogramme postpones or prevents the fer- 
mentation, and sugars or sirups in which the butter may be immersed 
have the same effect. So also does protecting it from atmospheric 
air in hermetically sealed jars set in cold water, or simply keeping 
it under fresh water which is renewed two or three times a day. 
Sometimes weak solutions of tartaric or acetic acid, three grammes 
to the litre (Hayem), are employed for this purpose. 



PLATE II. 




Butter x 40. 




BUTTERINE X 40. 



ANIMAL FATS, MAGNIFIED. 

{From Bulletin No. 13, Division of Chemistry, United States Agricultural Bureau). 



•MOTO BY CLJFFOKl) RICHARDSON. 



ANIMAL FOODS 97 

Pure fresh-butter fat is not crystalline, but old or rancid butter 
fat becomes so. 

Strong-tasting butter is not necessarily unwholesome, for the 
flavour may have been derived from the cow having fed upon dead 
leaves or turnips, and butter is even more sensitive than milk in 
transmitting unpleasant flavours. 

Butter will not support life for any length of time when taken 
alone, although 100 grains furnish 837 calories. Carnivora fed 
upon an exclusive diet of meat and fat do not grow fat, there- 
fore the original Banting treatment for obesity (see Obesity) has 
been modified by Ebstein and others by the free addition of butter 
to the diet. Taken in connection with other foods, however, butter 
is a highly digestible and nutritious food, and is often fattening, and 
it has been wittily said that " if bread is the staff of life, butter is its 
golden head." 

In weak stomachs the digestion of butter is improved by spread- 
ing it thoroughly in thin layers upon bread, or allowing it to soak 
into hot toast. It is thus prevented from floating about in the man- 
ner which coats the food and walls of the stomach and retards gastric 
secretion (Brunton). Most persons eat about an ounce a day of but- 
ter, but many eat double that quantity. Its annual production in the 
United States exceeds one billion pounds. 

The use of oleomargarine and butterine as substitutes for butter 
are described under the heading Fats and Oils. 

4. Buttermilk. — Buttermilk is the residual milk left after churn- 
ing and removing the fat. It is wholesome and diuretic, and makes 
a capital beverage for those patients who fancy its peculiar sour 
taste. It contains albumin and finely coagulated casein, salts, water, 
and sugar, which is largely converted into lactic acid. Its fuel value 
is about that of skimmed milk — 165 calories per pint — and its com- 
position resembles skimmed milk, but it contains a little less pro- 
tein and carbohydrate and a little more fat. A pint of it contains 
as much nourishment as two ounces of bread or a large potato 
(A. C. True). It should be drunk fresh, for it soon decomposes. 
Some patients can digest it who are unable to take ordinary milk. 
In those disorders in which the digestion of protein and fats is poor 
it may be better borne than milk. 

It is of especial value in chronic gastric catarrh with atrophy of 
the gastric glands (Eulenburg). A " buttermilk cure " is sometimes 
practised after the manner of the " whey cure " (see Dietetic 
" Cures "), but buttermilk cannot long be depended upon as an ex- 
clusive diet. 

5. Cheese. — Cheese is the casein of milk separated by rennet, 
which includes some of the fat and salts, but the potassium salts are 
removed by the rennet. There are many varieties, prepared in dif- 
ferent ways, but the two chief classes are hard cheeses and soft 



9 8 



FOODS AND FOOD PREPARATIONS 



cheeses, the former being pressed and salted. Cheese forms a highly 
nutritious food and an important article of commerce. In countries 
where meat is scarce and dear the peasantry consume large quanti- 
ties to supply the nitrogenous element of their diet, and, weight for 
weight, cheese contains about twice as much protein as meat 
(Parkes). They use for this purpose the heavier, less highly fla- 
voured cheeses. The wealthy classes eat cheese more as a condi- 
ment, taken after meals, and therefore they require higher flavoured 
varieties, which please the palate and excite the secretion of gastric 
juice. Eaten in moderation, such cheeses are an aid to digestion. 
Taken with milk, cheese tends to reduce the size of the coagulae in 
the stomach. Old " poor " cheese — 1. e., cheese made without fat, 
consisting of almost pure casein — is difficult to masticate thor- 
oughly, and is slowly dissolved in the gastric juice, hence it is slowly 
digested. It may act as a gastric irritant and be hurried into the 
intestine to excite indigestion there. Such cheese may be rendered 
more digestible by cooking it after grating with bicarbonate of potas- 
sium in the proportion of a quarter of an ounce to the pound of 
cheese. Cheese which retains some fat is friable, light, and easy of 
digestion. 

About 250,000,000 pounds of cheese are annually produced in the 
United States alone, and much so-called foreign cheese is produced 
in this country. 

The kinds of cheese differ somewhat in composition, but in gen- 
eral they may be said to contain from 35 to 55 per cent of water and 
from 10 to 20 per cent of fats, 20 to 30 per cent of casein, and about 
6 per cent of salts. 

Cheese is rich in fat or in flavour according as it is made from 
whole or skimmed milk. Cream cheese contains about yy per cent 
of fat, and the highly flavoured Roquefort, Edamer, Cheshire, and 
Emmenthaler, or Schweizer cheeses have a similar quantity, and are 
nutritive when they can be digested. 

Bauer's analysis of cream cheese places the fats much lower, and 
the casein is also at a minimum. 

Bauer s Analysis of Cream Cheese 





Water. 


Nitrogenous 
matter. 


Fat. 


Extractives. 


Ash- 


Cream cheese 


35.75 
46.82 
48.02 


7 .i6 

27.62 
32.65 


30.43 

20.54 

8 41 


2-53 
2.97 
6.80 


4 13 
3-05 
4.12 


Skimmed milk 



Cheese is usually prepared from sweet milk. The coagulation is 
accomplished in a few minutes by the addition of the ferment rennin 
with gentle heat (120 F.). The heat secures firmer coagulation. 
Casein may also be coagulated by acids. A little salt is added ; the 
curd is strongly pressed in a mould, and the expressed fluid is called 



ANIMAL FOODS 99 

" whey/' The curd is then salted and dried on the surface by fre- 
quent turning in the air. The harder cheeses are made under higher 
temperature and pressure. Cheese is kept for a time to " ripen," by 
fermentation or decomposition. If the decomposition goes too far, 
it develops leucin and tyrosin. The casein may become soluble in 
water, producing soda albuminate and peptones. The " riper " a 
cheese the greater is its value as a condiment. 

During the ripening volatile fatty acids are evolved from the fatty 
matter present, which occasion the odour and flavour. The casein 
also undergoes change, and is partially converted into fat (Foster). 
It may putrefy and evolve ammonia, or even become poisonous. 
Ripening, when not carried too far, makes cheese more friable, and 
hence more digestible. 

Cream cheese is fresh, and usually not ripened, but Neuchatel is 
ripened. 

Pot cheese is eaten fresh after the whey has been expressed. It 
contains : Water, 60.27 P er cent I casein, 24.84 per cent ; fat, 7.33 per 
cent ; ash, 4.02 per cent ; milk sugar and lactic acid, 3.54 per cent. 

The quality of cheese depends upon the richness of the milk in 
fat. In the richest cheeses made of whole milk, such as Stilton, 
double Gloucester, Gorgonzola, and Roquefort, cream is added. 
Single Gloucester, American, and similar cheeses are made from 
milk from which the cream has been removed. Dutch, Suffolk, and 
Parmesan cheeses are also made from skimmed milk, and are " poor." 
Being nearly pure casein, they are hard to digest in bulk. These 
latter varieties keep well, and become hard enough to be grated. 
Fat separates the flocculi of casein and makes cheeses soft, friable, 
and rich, but they sooner decay. 

The tw r o soft cheeses most used in this country are Camembert 
and Brie. 

Camembert is a cheese made of whole milk, which is very care- 
fully dried under regulated temperature. It requires three or four 
weeks to ripen. This cheese, as well as the following variety, is 
made in St. Lawrence County, Pa., as well as in Europe. 

Brie cheeses are manufactured in three grades of richness, accord- 
ing to whether the milk is whole, partly skimmed, or skimmed. 

Roquefort is a hard cheese made in the department of Aveyron 
from goat's milk, partly skimmed and coagulated with rennin. The 
curd is then pressed for half a day, dried for ten or twelve days, and 
ripened in caves. This cheese is streaked with bluish lines, which are 
formed by the addition of a mould which grows on stale rye bread. 
This cheese is also made along the shores of the Great Lakes in this 
country, where conditions of climate, pasturage, and water favour its 
production. 

Gruyere was originally a hard Swiss cheese, but is now made also 
in France and elsewhere. It is dry, aerated with large holes, and it 



L.ofC. 



IOO FOODS AND FOOD PREPARATIONS 

can be crumbled. It is manufactured in three grades, according to 
the degree of skimming of the milk, and the curd is cooked a short 
time before it is pressed. It has a somewhat saltish taste. 

Gorgonzola is a Piedmontese cheese made with hot and cold curds 
from two milkings, which do not perfectly unite, but which form 
minute interstices m which a green mould called " parsley " grows 
and imparts a high flavour (Clark). The curd is hung in hempen 
cloths to ferment. It is well salted. 

In the United States much of the cheese manufactured is of the 
common sort called " American cheddar," but Neuchatel, Stilton, 
pineapple, and other more highly flavoured varieties are also exten- 
sively produced. " Swiss " cheese is made in Ohio and Wisconsin. 
An imitation cheese is also prepared from a mixture of one part lard 
and two or three parts milk, mixed or emulsionised at 140 F. This 
emulsion is then added with buttermilk to skimmed milk, so that the 
finished product contains about 14 per cent of lard (Caldwell). 

Toasted cheese is one of the most indigestible articles of diet, 
unless the cheese is new, " poor,"' and cut thin. " Welch rarebits " 
are notoriously difficult of digestion, although highly nutritious when 
absorbed. It is an old saying of such cheese that it is " gold in the 
morning but lead at night." 

Certain low organisms, moulds, fungi, etc., flourish in cheese and 
make it very irritant to the stomach. Such are the Aspergillus glauctts 
and S porendoneum casci, both of which give a red colour, the cheese 
mite (A cams domesticus) and the maggots of a fly (Piophilia casei). 
Bad cheese has been known to produce poisonous symptoms (see 
Ptomaine Poisoning) resembling those of poisoning by sausage 
meat. 

Plasmon is an albumin food made from milk from which the fat 
has been removed. It is practically a dried form of casein. It is 
a tasteless, odourless, white, dry powder, soluble in water. It may 
be given every hour or two in teaspoonful doses in ten tablespoonfuls 
of water, or with an equal quantity of sugar an ounce of plasmon 
may be stirred into half a pint of boiling milk (C. Virchow). It may 
be added to broths and gruels, or to such starchy foods as boiled 
rice or mashed potatoes. This food contains over 90 per cent of 
pure protein in very digestible form. Plasmon biscuits and a plas- 
mon chocolate are also manufactured. 

Nutrose or casein-sodium is a form of milk casein which may 
be added in half-ounce doses to broths, gruels, or cocoa, in which it 
is soluble. It contains, according to Bruno Oppler, about 90 per 
cent of pure proteid. It furnishes a small volume of feces when this 
is desirable after operations upon the intestines. 

Sanose is an albuminous food consisting of 80 per cent of pow- 
dered casein and 20 per cent of egg albumin. It is a white, odour- 
less, tasteless powder forming an emulsion in water. It may be given 



ANIMAL FOODS IOI 

in milk, cocoa, purees, or soups. From two to six tablespoonfuls 
may be given daily. 

6. Whey. — Whey is the residuum of milk from which the casein 
and fat have been removed as cheese by the action of rennin or other- 
wise. It contains, in addition to water, salts, especially of potassium, 
a little lactalbumin, and lactose. It is apt to turn sour, but is fairly 
digestible even then, and its taste may be disguised by the addition 
of nutmeg and sugar. 

It makes a palatable, mildly diuretic drink, which is enjoyed by 
invalids. In Europe several " whey cures " have been established 
for the treatment of renal disease, dropsical affections, etc., but 
whey is not in any case a specific, and its dietetic value is greatly 
overrated. 

Yeo gives the following simple directions for the preparation of 
whey for invalids : Boil a pint of milk with one to two teaspoonfuls 
of lemon juice, strain in muslin, and express all fluid from the curd. 
Break the curd up first, and much fat and some finely divided casein 
will go into whey. Add beef tea or milk juice, or tgg yolk in hot 
water. 

Eggs 

About nine billion eggs are produced annually in the United 
States (Clark). Eggs contain all the ingredients necessary to sup- 
port life and develop the organism. Like milk, they constitute a 
complete food, for out of an egg the entire structure of the bird — 
its bones, nerves, muscles, viscera, and on some birds even feathers 
— are developed previous to hatching. The inner portion of the 
shell is dissolved by phosphoric acid to furnish phosphates for the 
bones. 

The average weight of a hen's egg, according to Bauer, is 50 
grammes, or about 2 ounces, divided as follows : Shell, 7 ; white, 27 ; 
yolk, 16 grammes. The eggs of pullets are smaller than those of 
old hens. 

Composition of a Hens Egg (Lawes and Gilbert) 

Fresh weight 1.8 ounce. 

Dry weight o . 45 

Fat o. 198 

Mineral matter o . 025 

Nitrogen o . 036 

Carbon o 275 

Or in percentage : 

Water 70 . 00 per cent. 

Dry matter 30 . 00 " 

100.00 per cent. 

Nitrogen 2 . 00 per cent. 

Carbon I7«5 2 



102 FOODS AND FOOD PREPARATIONS 

In artificial digestion experiments it is customary to estimate 
about four hundred grains of albumin to the egg. 

Hens' eggs principally are used for food, but the eggs of ducks, 
geese, and guinea-fowl are also eaten, and occasionally those of such 
wild birds as the plover and sea birds. Along the Texan coast the 
eggs of gulls, terns, and herons were formerly gathered for food, 
those of the gull and murre on the Farallone Islands off the coast of 
California, and those of the laughing gull off the eastern coast of 
Virginia. Terrapin eggs are eaten with the flesh of the animal, and 
various forms of fish eggs are esteemed for food, as those of the 
sturgeon (caviare) and shad (roe). 

The shell of a hen's egg weighs about one hundred grains. Its 
colour bears no relation to the nutrient value of the egg, but white 
shells are heavier than brown. An egg consists approximately of — 

Shell — ii parts Carbonate of lime. 

Yolk — 32 parts : Proteid ( vitellin) 15.7 per cent. 

Fat 33-3 ' 

Ash 1.1 ;< 

Water 49.5 

Total calories *. 1,705 

White— 57 parts : Proteid 12.3 per cent. 

Fat 2 

Ash 6 " 

Water 36. 2 

Total calories , 250 

The yolk is very complex. Besides the proteid vitellin, it con- 
tains three fats, colouring matter, nuclein, lecithin, and salts of iron, 
calcium, magnesium, and potassium. 

Egg albumin is not pure, but consists of four albuminoid and 
mucoid bodies, the chief of which is ovalbumin, together with a trace 
of carbohydrate. The phosphorus equivalent is 0.03 per cent phos- 
phoric acid (C. F. Langworthy), whereas that of trie yolk exceeds 
1 per cent. 

If the absorption of eggs from the intestine is delayed, decom- 
position ensues with production of sulphuretted hydrogen and am- 
monia, which cause considerable gastro-enteric disorder. The yolk 
of egg is particularly responsible for this. It is therefore a matter 
of great importance to serve only eggs which are absolutely fresh 
to invalids. No egg having an odour of stale, old straw should ever 
be offered. There are two simple methods by which the nurse may 
test the freshness of an egg : 

1. Hold the egg between the hands so that the light of a candle 
shines through it. If fresh, it is more transparent in the centre ; if 
stale, at the ends. 

2. Make a solution of two ounces of common salt in a pint of 



ANIMAL FOODS IO3 

water. An egg one day old will sink in this solution, but will not 
quite reach the bottom ; an egg three days old will barely float be- 
neath the surface, and an egg a fortnight old will float above the 
surface, only partially dipping beneath it (Siebel). This difference 
is due in part to loss of water, which after ten days equals 1.60 per 
cent; after twenty days, 3.16 per cent; and after thirty days, 5 per 
cent. It is also due in part to development of gases of putre- 
faction. 

With some persons eggs have a slight aphrodisiac effect, and 
they also promote costiveness. They should not be eaten in the 
following diseases : Flatulent dyspepsia, gastric dilatation, or any 
form of severe gastric derangement, severe acute Bright's disease. 
The flavour of eggs is modified by the food of the hen, those 
from hens fed on nitrogenous food instead of carbohydrates have 
poor odour and flavour and small yolks. An excess of onions 
in the hen's diet imparts the strong odour and taste of the vege- 
table to the eggs, about fifteen days after such food has been eaten. 
Eggs packed in stale bran or straw, or kept near decaying apples, 
acquire a bad flavour. Micro-organisms may penetrate the egg- 
shells and give rise to fermentation and decomposition. 

Raw Eggs. — Whole raw eggs are very popular in dietetics at 
present, and they are often prescribed when a nutritious, highly con- 
centrated diet is desired, and in cases of tuberculosis, some forms of 
anaemia, and various wasting diseases ; sometimes from eight to ten 
or twelve are given daily if they can be digested. They may be 
advantageously combined for such purposes with milk and salt or 
cod-liver oil, meat broths, soups, and purees. Beaten white of egg 
may be added to coffee, cocoa, wine, cream, or sweetened water. 

Eggnog is very nutritious, and is extensively prescribed in some 
non-febrile diseases, especially for the forced alimentation of phthisis 
and melancholia, and there are occasional cases of bilious habit in 
which eggs can only be digested when beaten 'in wine, but the com- 
bination of egg, milk, and sugar with alcohol, which constitutes 
eggnog, may produce nausea and vomiting in a feeble stomach, 
particularly in fever. For this reason whole eggs are unfit for 
fever patients, and if eggs are employed at all for them, the whites 
only should be used, prepared in the manner described in the fol- 
lowing section : 

Egg Albumin, when eaten raw or almost raw and properly diluted 
with milk or water, is well absorbed. It may also be predigested, 
and it should be flavoured with lemon juice, or sherry or other wine, 
coffee, cocoa, or cream, and sweetened water; otherwise it is taste- 
less and disagreeable, and but few can continue to eat it in any con- 
siderable quantity. (See Receipts, Preparations of Eggs.) When 
the fresh white egg albumin is beaten it incloses bubbles of air 
which expand by heat when the albumin is mixed with dough, mak- 
9 



104 FOODS AND FOOD PREPARATIONS 

ing it porous, as in the case of sponge-cake. Old eggs lose this 
quality of frothiness. 

Egg albumin is used by Ewald to prepare fresh albuminate of 
iron. He adds two tablespoonfuls of a solution of one part of white 
of egg in two of water, to a teaspoonful of a 2- or 3-per-cent solution 
of ferric chloride. To be taken through a tube. 

Protogen is an uncoagulable form of egg albumin prepared by 
action of formalin. It may be given either by mouth or in nutrient 
enema. 

The Cooking of Eggs. — Albumin, or the " white " of an egg f is 
altered physically but not chemically by processes of cooking. At 
about 1 34 F. delicate fibrillar of coagulated albuminous material be- 
gin to stretch through the substance, and they increase with the 
temperature up to 160 F. The fibrillar are so numerous that the 
entire mass is coagulated, but is still of a soft or gelatinous con- 
sistence. 

It has been observed by Tarchnoff that the coagulum thus formed 
in the eggs of birds which, like the chick, are hatched with feathers, 
becomes white and opaque, whereas that of the eggs of birds which, 
like the plover, are hatched without feathers, is more transparent. 
If the coagulated albumin is heated still further, it becomes more 
and more dense, hard, dry, and brittle. When heated beyond the 
boiling point, or 212° F., it forms a very tenacious, gluey substance, 
which can be used as a cement for mending broken china. 

Eggs baked in puddings or in any other manner form one of 
the most insoluble varieties of albumin possible. A raw egg is ordi- 
narily digested in the stomach in one and a half hour, but a baked 
egg requires from three and a half to four hours. 

The principle involved in this account of the cooking of an egg 
is further illustrated by the process of overcooking beefsteak. When 
strong heat is too long applied in the process of broiling, the albumin 
of the meat becomes dried, shrivelled, and comparatively tasteless ; 
and eggs cooked for persons with delicate digestions, instead of being 
" boiled " in water at 212 F., should be placed in water at a tem- 
perature between 170 and 180 F., and immersed for fully ten min- 
utes, at the end of which time they will be found of a uniform 
gelatinous consistence, very palatable, and not too tough to be 
readily acted upon by the gastric juice. If a cooking thermometer 
is not at hand, the water may be previously brought to the boiling 
point and then set aside, when in a moment or two it will cool to 
the proper temperature. This should be a little above the coagula- 
tion point of the egg albumin (134 F.), because the process of rais- 
ing the temperature of the egg is a slow one, and the water loses 
heat in warming the egg (Williams). Eggs cooked in this manner 
are found to have the yolks more firmly coagulated than the white, 
which remains quite tender. A practical way of attaining the above 



ANIMAL FOODS 105 

result is to pour a quart of recently boiled water over two eggs in 
a bowl and let them stand for ten or twelve minutes. 

Another excellent way to cook an egg, as suggested by Henry, 
is to immerse a teacup in boiling water until it becomes thoroughly 
heated. It is then removed and the egg is broken and dropped 
into it, and the cup may be wrapped in a cloth. Sufficient heat is 
retained by it to cook the egg without water and remove any raw 
taste. 

The yolk really coagulates at a lower temperature than the white, 
although as eggs are commonly cooked it does not have an oppor- 
tunity to coagulate first. The former is composed of albumin and 
casein with fat (Lehmann). In the ordinary rapid cooking of eggs 
in boiling water the white is firmly set before there is time for the 
temperature of the interior of the egg to be thoroughly raised, and 
consequently the yolk is softer than the white. The shell of the egg 
facilitates the process of slow cooking of the albumin by protecting 
the interior and preventing the escape of the contents by solution, 
just as in the cooking of fish or flesh in water, the latter should 
be hot enough to immediately form an external coagulum of albu- 
min sufficiently dense to prevent the diffusion of albuminous mate- 
rial and salts into the water; 

Custards composed largely of eggs, although unfit for active 
fever, are very useful adjuncts to a convalescent dietary in recovery 
from typhoid fever or other acute diseases. 

In the making of omelettes and " scrambled " eggs the white is 
thoroughly mixed with the yolk, and the egg is more digestible than 
when fried or cooked so much that the albumin is hard. 

Preservation of Eggs. — Eggs decompose from the admission of 
germs through their porous shells. To prevent this occurrence it 
is necessary to protect the eggs from contact with air. When first 
laid, eggs have a protective mucilaginous coating, which is, how- 
ever, removed by washing. They may be coated with varnish, 
paraffin, tin foil, butter, glycerin, vaseline, or any fat or oil not liable 
to become rancid. A 2- or 3-per-cent solution of salicylic acid may 
be added to the oil. Packing in sawdust or bran also excludes the 
air to a slight extent. Lime with cream of tartar preserves eggs, but 
alters their taste. 

According to C. F. Langworthy (U. S. Department of Agricul- 
ture Bulletin No. 128, 1901) the best preservative substance is a 10- 
per-cent solution of water-glass, in which eggs will keep fresh for 
three and one half months. Eggs also preserve their freshness for 
as much as a year in cold storage at 30 to 40 F. Eggs so stored 
must be turned twice a week to prevent gravitation of the yolk, 
causing its adhesion to the shell. 

Eggs are also preserved by drying, canning, and similar processes, 
when designed for shipment upon long voyages. 



106 FOODS AND FOOD PREPARATIONS 

Evaporated or desiccated eggs are dried in vacuo or otherwise by 
currents of warm air. Salt or sugar may be added, and the eggs are 
ground. Such eggs keep well, and are often used by bakers. 

Meats 

The Consumption of Meat. — The universal consumption of meat 
by civilised man is of more recent origin than is generally supposed. 
McCulloch states (Statistical Account of the British Empire, vol. ii, 
p. 502) that " so late as 1763 the slaughter of bullocks for the supply 
of the public markets was a thing wholly unknown even in Glasgow, 
though the city had then a population of thirty thousand." 

In the past decade or two the consumption of meat has increased 
enormously, especially in England, owing to the development of 
cheap refrigerating processes, canning, and increased facilities of 
transportation of live cattle. The beef from Australian and New 
Zealand cattle is obtainable in London, and that of Texan cattle in 
New York in a state of perfection and cheapness which far exceeds 
that of animals raised close at hand. In London during the last 
twenty years of the nineteenth century the per capita consumption of 
meat rose from 112 to 122 pounds. There is a popular belief that 
the eating of meat increases both bodily vigour and mental capacity, 
and that a man fed upon animal food is livelier, keener, and stronger 
than the exclusive vegetarian. (See Animal and Vegetable Foods 
Compared, p. 33.) This comparison may not hold in all cases, nor 
with all people and tribes of man — as, for example, the Japanese and 
many African tribes — but it applies very well to those who have to 
meet the exigencies of advanced civilisation. Liebig, in extolling 
the advantages of a liberal meat diet, wrote : " It is certain that three 
men, one of whom has had a full meal of meat and bread, the second 
cheese or salt fish, and the third potatoes, regard a difficulty which 
presents itself from entirely different points of view." 

It is true, however, that too much meat is eaten by many persons 
for maintenance of the best health. The annual per capita consump- 
tion of meat has almost doubled during the past half century. It is 
estimated in pounds as follows: In the United States, 120; England, 
105; France, 74; Germany, 69. 

Very large quantities of meat — much more than is necessary for 
sustenance — are absorbed when eaten, although a few undigested 
muscle fibres may appear in the stools. 

A meat diet, if long continued, tends to produce scurvy, and the 
absence of meat favours the occurrence of anaemia in many persons. 
In general, those diseases in which an exclusive meat diet, or a diet 
composed almost exclusively of animal food, with perhaps a mini- 
mum of dry bread, is found beneficial, are the following: Flatulent 
dyspepsia, chronic gastritis and gastric catarrh and dilatation, dia- 



ANIMAL FOODS 



I07 



betes, intestinal dyspepsia, phosphaturia, obesity, and some cases of 
chronic dysentery. Meat should also enter largely into the diet of 
consumptives and anaemic subjects. 

It is well to prohibit the consumption of meat in fevers, acute 
and severe chronic Bright's disease, gout and rheumatism, and to 
reduce it in lithaemia and oxaluria. 

Composition of Meats. — Meat from any animal is composed of 
muscular fibres, but it necessarily contains those structures which 
were intimately associated with them, such as connective tissues, 
blood vessels, nerves, and lymphatic vessels, and more or less adipose 
tissue. Meat which is very fat contains comparatively little water, 
as well as less nitrogenous matter than lean meat. 

In one hundred parts of flesh there are, according to Schloss- 
berger and v. Bibra : 



Water 

Solids 

Soluble albumin, colouring matter . . 

Glutin 

Alcoholic extract 

Fats 

Insoluble albumin, blood vessels, etc 



Ox. 



77-50 

22.50 

2.20 

1.30 

1.50 

i7-5o 



Pig. 



78.30 

21.70 

2.40 

0.80 

1.70 



Man. 


Fowl. 


Carp. 


74-45 


77-30 


79.78 


25-55 


22.7 


20.22 


1-93 


3-0 


2-35 


2.07 


1.2 


I.98 


3-7i 


1.4 


3-47 


2.30 




I. II 


15-54 


16.5 


13-31 



Composition of Various Meats 



Constituents. 



Nitrogenous matters 

Fat 

Carbohydrates 

Saline matters 

Non-nitrogenised organic matters, 

and loss 

Water 

Total 



Lean 
beef 

(Pavy). 


Fat 
beef 

(Pavy). 


Lean 

mutton 
(Pavy). 


Fat 
mutton 
(Pavy). 


19-3 
3.6 


I4.8 
29.8 


18.3 
4.9 


12,4 
31- 1 


5-i 


4.4 


4.8 


3-5 


72.0 


5I-0 


72.O 


53-o 


100. 


IOO. O 


100.0 


100. 



Veal 
(Pavy). 



16.5 

15.8 

4-7 
63.O 



Constituents. 



Nitrogenous matters 

Fat 

Carbohydrates 

Saline matters 

Non-nitrogenised organic matters, 

and loss 

Water 

Total 



Fat 

pork 

(Pavy). 


Dried 

bacon 

(Pavy). 


Calves' 
liver 

(Payen). 


Fois 
gras 

(Payen). 


9.8 
48.9 

2-3 

39-o 


8.8 

73-3 
2.9 

15.0 


20.I0 
5.58 
0-45 
1-54 

72.33 


13-75 

54-57 

6,40 

2.58 

20.70 


100. 


100. 


IOO.OO 


100.00 : 



Sheep's 
kidneys 
(Payen). 



I7.250 
2.125 

I. IOO 

1.325 
78.200 



108 FOODS AND FOOD PREPARATIONS 

Raw Meats. — -There is a prevalent fashion of prescribing raw- 
meat, and in some diseases, such as dysentery or chronic gas- 
tritis, it is useful, but it should not be given with the idea that it 
possesses any special curative virtue from the fact of being raw. 
Beef, mutton, and ham are all eaten in this condition. Meat is dis- 
tasteful to most persons in this state and soon palls upon the appe- 
tite, and may excite positive loathing. There is a natural aversion 
to raw flesh among even the lowest tribes of man, who only consume 
their meat raw from excessive hunger or when fire is unobtainable. 
Even the primitive Australian savage cooks his reptiles and worms. 
Raw meat has no advantage either in digestibility or nutrient power 
over moderately cooked or " underdone " meat. Some danger has 
been attributed to eating raw meat on account of the possibility of 
acquiring intestinal worms through it, but the fear of this is much 
exaggerated. 

On the other band, meat is easily altered and made innutritious 
by prolonged cooking. Overdone meat is indigestible and tasteless. 

If meat is too long boiled it becomes insipid and useless as an 
aliment, and the resulting soup is not a full substitute for it. Meat 
should never be cooked during rigor mortis. 

Hall and Kane both declared that in their arctic experience 
fresh raw meat was a preventive of scurvy, but that cooked meat 
was not. 

Digestibility of Meats. — Among the circumstances which affect 
the digestibility and nutrient power of meats are the age at which 
the animals eaten were killed, and the care bestowed upon them in 
feeding, shelter, and transportation. Animals which have been 
underfed, ill-treated, and worried yield very inferior meat. 

Almost all meat is tougher immediately after killing, and im- 
proves on being kept for a day or two. Violent exercise is believed 
to increase the tenderness of the meat of hunted animals. 

In general, the flesh of young is more digestible than that of old 
animals, provided they are not still suckling. 

It would be convenient if meats and animal foods of all kinds 
could be arranged in a table of comparative digestibility, but such 
tables are necessarily inaccurate, if not actually misleading, owing 
to the great variations produced by the character of the particular 
samples of food used, by the time and manner of cooking, by the 
condition of the digestive organs, and by personal idiosyncrasy. No 
two tables of this kind given by different authors are found to agree 
in all respects. 

The following table is offered as an average of the ease of diges- 
tibility of animal foods, the time required for the completion of gas- 
tric digestion being the chief standard, but some foods may be well 
enough digested although they require half an hour or so longer time 
than others. 



ANIMAL FOODS IO9 

Table of Comparative Digestibility {commencing with the Most Digestible, 
and ending with the Least Digestible of Meats and Other Common Ani- 
mal Foods) 



Oysters. 

Soft-cooked eggs. 
Sweetbread. 

White fish, boiled or broiled, such as 
bluefish, shad, red snapper, weakfish, smelt. 
Chicken, boiled or broiled. 
Lean roast beef or beefsteak. 
Eggs, scrambled, omelette. 
Mutton, roasted or boiled. 
Squab, partridge. 
Bacon (crisp). 

Roast fowl, chicken, capon, turkey. 
Tripe, brains, liver. 



- Roast lamb. 
' Chops, mutton or lamb. 

Corned beef. 

Veal. 

Ham. 

Duck, snipe, venison, rabbit, and other 
game. 

Salmon, mackerel, herring. 

Roast goose. 

Lobsters and crabs. 

Pork. 

Smoked, dried, or pickled fish and 
meats in general. 



The table given below is published by E. Jessen as the result of 
giving test meals of single articles of food. The stomach was first 
cleansed and emptied by siphonage, then a hundred grains of meat 
were introduced with eight ounces of water. Samples of the di- 
gested stomach contents were from time to time withdrawn, and the 
complete disappearance of all muscular fibre when examined by the 
microscope occurred as follows : 

Beef, raw, chopped fine 2 hours. 

Beef, half cooked i\ " 

Beef, well cooked 3 " 

Beef, thoroughly roasted 4 '' 

Mutton, raw 2 " 

Veal, cooked i\ n 

Pork, cooked 3 " 

These estimates fall somewhat below those of other writers, and 
for comparison he gives the time for digestion of six hundred cubic 
centimetres of raw cow's and goat's milk as three and a half hours, 
and that of boiled milk as four hours, which is too long. 

Beef. — The composition of beef varies with the feeding of the 
animal. A young steer from two and a half to five years old fur- 
nishes the best meat. If the animal is lean the meat may yield from 
70 to 75 per cent of water and about 20 per cent of nitrogenous 
material, furnishing about 415 calories per pound, with 2 or 3 per 
cent of fat ; but if very fat when killed, the percentage of both water 
and nitrogenous material is considerably reduced, while that of the 
fat may be as high as 25 per cent, or even more. As a general aver- 
age, one third of beef is nutritious material, the remainder is water 
and bone. 

Beef fat is composed of glycerides of fatty acids. It melts at 
from 41 ° to 50 C. Stearic and palmitic acids are present in the 
proportion of three to one of oleic acid. 



110 FOODS AND FOOD PREPARATIONS 

The equivalent of beef is sometimes stated in terms of other 
foods. A pound of lean beef is believed to equal in nutrient value 
two and a half pints of milk, half a pound of bread, and about three 
eggs, but these are only approximate figures. 

Fresh beef can be eaten longer continuously than any other kind 
of meat. In this respect it resembles bread and rice. Attempts 
have sometimes been made on wagers to eat quail or partridge three 
times a day consecutively for a month, but disgust is sure to follow 
after a week or two, no matter how much such food is varied in the 
cooking, and by the end of a month it may excite extreme loathing, 
and even nausea and vomiting. 

Chipped beef is prepared, like corned beef, by pickling for a 
month, when it is smoked for two days and dried for a fortnight, 
after which it is sliced thin by machinery and is ready for packing. 

Beef Preparations for the Sick. — Beef is so important a food for 
well and sick alike that many attempts have been made to improve 
its digestibility for the latter. 

Most of these efforts are aimed at concentrating the meat by re- 
moving all indigestible connective-tissue fibre, the muscle sheaths, 
sarcolemma, and blood vessels. 

In some cases the process of concentration is carried still further 
and water is driven off by evaporation, or some of the active prin- 
ciples of the meat are extracted and condensed. Sometimes the 
meat is predigested. Different meats may be prepared in these ways, 
but the best lean beef free from coarse fibre is usually preferred. 

It is impossible within the limits of this work to even name all 
the meat extracts, powders, etc., that have been produced, but a 
few of the typical ones which are most in use will be described below. 

It was long ago shown by Schiff that many fluid substances, such 
as meat extract, soups, peptones, and even vegetable purees when 
taken at the commencement of a meal, on being absorbed into the 
blood, favour the flow of gastric juice. This is true also of peptones 
injected into the rectum, so the effect is not wholly due to local stim- 
ulation of the inner surface of the stomach. 

Much attention has of late been given to the predigestion of 
meat, and especially to the production of albumoses, which are more 
soluble and assimilable than undigested meat albumin, and which are 
said to possess greater nutritive property than peptones. 

The beef extracts made in this country usually have a less dis- 
agreeable taste and odour, and are lighter in colour than those made 
of South or Central American beef. 

In general, about three grammes of meat extract constitute a 
good soup ration, and such preparations are often valuable for addi- 
tion to invalid soups and broths when thickened with eggs, rice, sago, 
pearl barley, macaroni, ground toast, etc. 

The preparations of meat for the sick are both solid and fluid. 



ANIMAL FOODS III 

Solid Meat Preparations. — Scraped meat is best made from tender 
beefsteak, broiled for a few minutes over a brisk fire, but rare roast 
beef or mutton chops may be used. With a dull knife or an iron 
spoon the pulp is scraped out. The indigestible and less nutritious 
connective-tissue sheaths of the muscle fasciculi are broken and left 
behind, while the fibres themselves (or their myosin) are obtained 
in the form of a soft unirritating mass which is readily acted upon 
by the gastric juice. The pulp may be run through a sieve. It is 
then salted, and it may be made into little balls and browned just 
before eating. This is done by placing the balls on a hot frying pan, 
which is not greasy, and turning them over so that the outside be- 
comes well seared. They should then be set aside on a cooler part 
of the stove or oven and allowed to remain until the raw red colour 
of the interior turns slightly to drab. 

Some patients prefer to eat the meat lightly cooked, spread as 
a sandwich between thin slices of bread and butter. This meat 
may be fed to infants in their second year, and the meat balls and 
sandwiches are invaluable in the treatment of chronic gastritis, dila- 
tation of the stomach, typhoid convalescence, and other affections. 

Mosquera's beef meal is made by digesting fresh tender lean beef 
with pineapple juice until the muscle fibre is almost completely con- 
verted into peptones. After digestion the preparation is desiccated. 
Chittenden's analysis of this meal shows it to contain 90 per cent of 
nutriment, 13 per cent of which is fat and 7 7 per cent is protein. Of 
the latter, almost half consists of albumoses and peptones fit for 
prompt absorption. The remaining portion is believed to be in a 
condition in which it is more digestible than plain meat. The beef 
meal is tasteless and odourless, which are decided advantages, as 
it can be flavoured according to preference. It should be salted, 
and it may be added to broths and soups. D. D. Stewart advises 
its use with equal parts of sugar and cocoa. This mixture is added 
to hot mlik. 

Mosquera's beef jelly is made in a similar manner, but is evaporated 
to the consistence of a solid extract. Analysed by Ludwig, it was 
found to contain only 3 per cent of insoluble material, and of the 
soluble portion 53 per cent consists of albuminoids which were nearly 
all peptones. It is of pleasant taste and odour, and is highly nutri- 
tious. Dissolved in boiling water, it may be given alone with a pinch 
of salt or added to re-enforce any broth, gruel, consomme, beaten 
eggs, or milk. The beef jelly is even more digestible than the meal. 
It is sometimes combined with cocoa. 

The beef meal and jelly are both excellent for use in gastritis, 
gastric catarrh, ulcer, and carcinoma, and many forms of enfeebled 
assimilation. 

Bcnger's peptonised beef jelly is another good beef preparation 
much in vogue in England for the same purposes as Mosquera's 



112 FOODS AND FOOD PREPARATIONS 

preparations. It may be taken cold or dissolved in hot water as a 
concentrated beef tea, representing a large amount of meat fibre. It 
is a useful stimulant for the aged who have feeble digestive power. 
It may be given to them in teaspoonful doses. 

Tropon is a condensed proteid preparation of granular consist- 
ence, said to contain 89 per cent of protein (Kleine). It is tasteless, 
insoluble, and may be added to milk, broth, rice, or other food, and 
several drachms may be given daily. 

Darby's fluid meat is a moist extract which has a strong meaty 
taste. It can be eaten spread on thin bread and butter or cracker, 
or it may be dissolved in hot water. 

Powdered beef is made as follows : 

Chop lean beef into small pieces, dry on a water bath or in an 
oven with a slow fire, and powder in a coffee mill or with a machine 
constructed for the purpose. Do not overdry. This powder can be 
mixed with hot water or any form of soup, milk, chocolate, grog, or 
punch. In process of drying, which occupies from five to twenty- 
four hours, the meat loses rather more than four fifths of its weight 
(Huggard). 

Dujardin-Beaumetz's " grog de la pondre de viande " is prepared as 
follows : Take two tablespoonfuls of meat powder, three dessert- 
spoonfuls of essence or sirup of rum punch, and add milk enough to 
make quite fluid. In this way he claims that the equivalent of three 
and a half pounds of meat may be given daily. 

Debove, Dujardin-Beaumetz, and Peiper strongly recommend 
powdered meat for forced alimentation (see Suralimentation in 
Phthisis) to replace feeding by the stomach tube. 

Professor Finkler, of Bonn, has made a proteid food which he 
claims — 

" 1. Has the greatest amount of albumin possible up to 90 per 
cent. 

" 2. Is digestible up to almost its entire weight. 

" 3. Can be made equal in amount for each day. 

" 4. Keeps well indefinitely in all climates. 

" 5. Its flavour and taste do not interfere with that of other food. 

" 6. Its price is the lowest possible." 

This food consists of the nitrogenous parts of meat, fish, and 
legumes. It is odourless, tasteless, and forms a light yellow granular 
powder. Konig's analysis of this food follows : 

Protein. 89.87 per cent. 

Water 8.89 " 

Ash 1.24 " 

Fat 0.20 " 

Beef blood. — Dried beef blood, powdered, has been recommended 
by Regnard and others for use by addition to soups and various 



ANIMAL FOODS II3 

forms of foods. The taste and odour of dried blood is disagreeable, 
and the idea of eating it in any form is repugnant to most persons. 

It has also been used for rectal injection, but I have always ob- 
served it to cake inside the bowel, and there is very little evidence 
that it is absorbed at all. 

Meat lozenges are prepared by Mason as a convenient and port- 
able form of condensed food. Soup lozenges and capsules are also 
made. 

Beef peptonoids are prepared in powdered form by several manu- 
facturers ; one variety contains predigested and sterilised beef, milk, 
and gluten. 

Rudisch's beef peptone (or sarco-peptone) is a dark-brown, semi- 
solid paste, having a strong meaty odour and flavour. One pound 
of this preparation represents eight pounds of fresh lean beef. In 
addition to the extractive materials which are obtainable in ordinary 
beef tea, it contains predigested proteids in a form suited for prompt 
absorption. It may be eaten spread upon crackers or toast, or it 
may be dissolved in chocolate or almost any suitable fluid, either 
hot or cold. It is given in doses varying from half a teaspoonful 
or less for young children, up to a teaspoonful or tablespoonful for 
adults. If its flavour when dissolved in water alone is disagreeable 
or becomes tiresome, it may be altered by giving it ice cold, or by 
the addition of salt, celery salt, pepper, or Worcestershire sauce, and 
for children it may be sweetened with sugar. It is often added to 
milk, sherry, eggnog, gluten, and farinaceous gruels of oatmeal, rice, 
or arrowroot, or it may be used to re-enforce soups, broths, and 
jellies. 

The Maltine Company furnish a similar preparation which con- 
tains 70 per cent of albuminous material with phosphates, fat, and 
carbohydrates. 

The South American beef extract is a predigested preparation 
which, by the analysis of Kemmerich, contains, with other proteid 
matter, a large proportion — over 27 per cent — of albumoses and 
peptones, ready for immediate absorption. 

Somatose is a granular predigested meat powder which, accord- 
ing to analysis reported by Hildebrandt, contains 90 per cent of albu- 
moses (deutero- and hetero-albumose), and is free from peptones. It 
is of a yellowish colour, amorphous, finely granular, having but faint 
taste and odour. Dissolved in water, it forms a clear, light yellow or 
brownish solution, almost tasteless. It is not precipitated by heat 
or by strong acids. The latter, in fact, redissolve a precipitate 
which is formed by very weak acids. It is claimed for it that it is 
eight times as nutritious as meat, but estimates of this kind applied 
to artificial foods are always fallacious. Of course for an invalid 
who cannot digest any meat such preparations are indefinitely 
" stronger," but for those who can assimilate meat they are much 



114 FOODS AND FOOD PREPARATIONS 

weaker. Somatose can be injected in hypodermic solution without 
local irritation. It may be given as fine powder with bread and 
butter or spread upon toast. It is also administered like similar 
preparations in milk, mucilage, soup, cocoa, or coffee. When mixed 
with such substances it should be first stirred into a thin paste with 
an equal volume of the fluid and then added to the remainder. 

It is well tolerated by irritable stomachs and is speedily absorbed, 
and it possesses the advantage of having a less disagreeable taste 
than many preparations of meat. 

Eskay's Food is an albuminised food suitable for emergency 
feeding of infants and for adults with disordered stomach or bowels. 

Fluid Meat Preparations. — Beef juice contains serum, lymph, and 
blood. It is prepared as follows : A tender, thick, juicy beefsteak is 
broiled for several minutes over a quick fire so as to coagulate the 
outside and retain the juice well within. It is then cut into small 
pieces an inch or two in diameter and squeezed in a common lemon 
squeezer or, better, in a meat press, which is sold in hardware shops 
for this special purpose. The juice is salted, and for adults a little 
pepper may be added. It is best served warm, but if preferred it may 
be eaten frozen. This preparation is quite nutritious, although less 
so than scraped beef. 

When beef is chopped and squeezed under great pressure, juice is 
obtained from it in the proportion of two hundred and thirty grammes 
per one thousand of meat, but only about 6 percent is albumin (Bauer). 

Fresh beef juice is serviceable for feeding in many cases of severe 
gastric disturbance with vomiting and pain ; also in typhoid fever, 
and for feeding infants at the end of the first and in the second year. 
From one to three tablespoonfuls may be given at once, and it forms 
a good introduction for the stomach to solid food. It is usually 
much to be preferred to any of the foregoing extracts and other 
preparations. If desired, it may be pancreatinised like milk (see 
Pancreatinised Milk, p. 79). 

Beef Tea. — The nutritive strength of beef tea has formed a sub- 
ject for much discussion. The assertion is often made that it is a 
comparatively useless preparation, and it is said that a pint of it con- 
tains scarcely a quarter of an ounce of anything. Hassell estimates 
that fourteen pounds and a half of beef would be required to make 
enough tea to counterbalance the daily nitrogenous waste of one man. 
If rightly made, however, it may be nutritious, although the quan- 
tity of albuminous material which can be dissolved in it at any time 
is much less than that which exists in a similar volume of milk or in 
an egg. The preparation of beef tea should be conducted as follows : 
Tender lean raw beef is chopped into small pieces about a quarter of 
an inch in diameter and macerated in cold water for five or six hours. 
The water is to be added in the proportion of a pint to a pound of 
lean beef; ten drops of hydrochloric acid are then added, and the 



ANIMAL FOODS 11$ 

solution is gradually heated up to 160 F., but not more, for from 
fifteen to thirty minutes. This is best accomplished by placing the 
vessel in a larger outer vessel of boiling water. The water of the 
outer vessel communicates its heat to the inner one, but the contents 
of the latter does not boil because the evaporation from its surface 
prevents its temperature from rising to that of the outside water, 
which is nearer the fire. Various forms of water baths, which the 
French call " bain marie " or milk scalders, are sold which are con- 
veniently adapted for the process of making beef tea. 

The prolonged soaking of meat in cold water dissolves its mineral 
ingredients — chiefly chlorides and sulphates of potassium, and also 
extractives, principally creatin and creatinin and some lactid acid 
derived from the muscle fibres. There may also be a little albumin 
present, but the albumin of meat or muscle is very sparingly soluble 
in simple aqueous solutions, and hence it does not diffuse out readily 
into the water, but the addition of hydrochloric acid converts the in- 
soluble myosin into an acid albumin called syntonin, which is soluble 
in water. 

In making beef tea, more or less fat is apt to be derived from the 
meat which floats upon the surface and presents a very unappetising 
appearance. This should always be skimmed or strained, and if it 
collects on cooling, the operation can be repeated. A crust of bread 
dipped beneath the surface will remove the supernatant layer of fat. 
The materials which are present in beef tea prepared in this manner 
are not very nutritious, but they are mildly stimulating to the mucous 
membrane of the stomach and to the nervous system, and it is prob- 
able that they are for the most part absorbed directly from the gastric 
mucous membrane without passing beyond into the intestine. 

It is always desirable to give special attention to the proper fla- 
vouring of food for fever patients. In cases where a fluid diet is 
necessitated for many days in succession, much depends upon the 
willingness of the patient to take the food offered him, and a dread 
of too frequently recurring intervals of feeding and the positive 
dislike which the monotonous taste of certain meat preparations 
begets, react unfavourably upon the digestion. It is advisable to 
consult the individual taste of patients in this regard, and when they 
positively assert that they cannot take beef tea or bouillon or meat 
extracts in any form, their opposition may often be overcome by 
adding the expressed juice of some fresh vegetables of which they 
are fond. Carrots, turnips, celery, parsnips, and endives may be 
boiled alone or with an aromatic herb, such as parsley or green mint, 
and afterwards chopped fine and their juice expressed by squeez- 
ing them in a muslin bag. Such juices added to beef tea and broth 
impart an altogether different flavour, which may be varied from time 
to time by changing the vegetables (Yeo). 

The total quantity of albuminous material which can be obtained 



Il6 FOODS AND FOOD PREPARATIONS 

in the manner above described in a reasonable bulk of fluid is very 
little, but in febrile conditions it is usually good for the patient to 
ingest abundant water, and there is no objection to part of the fluid 
being taken in the form of beef tea. On the other hand, if patients 
have absolute anorexia they are soon wearied by the effort of swal- 
lowing, and it is preferable to give nitrogenous food in some more 
concentrated form. 

In fever, albuminous and gelatinous solutions aid in maintaining 
strength and diminish the tendency to exhaustion, and for this pur- 
pose the chief value of beef tea and beef essences is found to ex- 
ist, rather than for furnishing additional substance to the tissues. 

The objections to the use of beef tea are that its preparation re- 
quires time and care, and the taste soon becomes monotonous. It 
may be advantageously given, however, with vegetable extracts or 
beaten eggs, or gelatin may be put in to stiffen the mass into a jelly, 
which, when properly seasoned, is palatable. It may also be thick- 
ened with broken crackers, and with the addition of a little butter, 
pepper, and salt, it becomes much more nutritious ; or sago, arrow- 
root, or chocolate may be mixed with it. 

For infants the tea may be made weaker than for adults by using 
half a pound of lean rump steak to the pint of water. 

Bouillon, or the French pot au feu, is of little more value as an ali- 
ment or heat producer than beef tea or extractum carnis. It is a 
good vehicle for giving beaten or dropped eggs, flour, etc. It stim- 
ulates the nerves, but in a much less degree than alcohol. It has the 
advantage over the latter and over condiments that it is never poi- 
sonous. A good meat puree may be made by adding a tablespoon- 
ful of scraped beef to three or four tablespoonfuls of bouillon, warm- 
ing over a brisk fire until the meat turns of a faint drab colour, and 
seasoning with pepper and salt or a little butter. 

Beef broth is agreeable to invalids, but on the whole it is less nu- 
tritive than that made from chicken, veal, or mutton. As ordinarily 
made, it contains, besides salts and extractives, -J per cent each of fat 
and albumin and i per cent of gelatin. 

Liebig's extract of meat, or extractum carnis, consists of the 
flavouring extractive matters such as kreatin, isolin, decomposable 
haematin, and salts. Some of these substances are excrementitious, 
and on this account Masterman compares it to urine, although it 
contains less urea. 

A pound of mutton is represented by two fifths of an ounce of 
the extract. It contains no albumin or fibrin, and has in all but 2 
per cent of solids, hence its nutritive power is practically nil, but when 
regarded as a stimulant and so used, it removes fatigue, strengthens 
the action of the heart and nervous system, and improves the func- 
tional activity of the stomach, and in this manner aids the digestion 
of foods. There is no occasion for taking it in large quantities, and 



ANIMAL FOODS 117 

when this has been done, symptoms of slight ptomaine poisoning 
have been observed, such as heaviness and stupor (Yeo). The ex- 
tract has the advantage of keeping for years without decomposition, 
and it has been found that sometimes in cases of shock, especially 
after wounds received on the battlefield, its stimulant action has 
been considered almost equal to that of alcohol, and, bulk for bulk, 
it is certainly greater. 

Johnson's fluid beef is a digestible preparation, somewhat less dis- 
agreeable in taste than many extracts of meat. 

Valentine's meat juice is a much-used preparation which resembles 
Liebig's somewhat in its properties. 

Valentine's meat juice is a clear fluid of a deep claret-colour, hav- 
ing a meaty odour and strong meaty taste. It is prescribed in doses 
of one half to two teaspoonfuls, diluted in eight times its bulk of 
cold water, or it may be mixed with cracked ice. Its taste, which is 
disagreeable to many patients, is easily disguised by the addition of 
half a tumblerful of milk, or it may be mixed with light, farinaceous 
gruels (after they have cooled to 130 F.), or used to re-enforce soups 
and broths or cod-liver oil. Like Liebig's extract, it may be given 
by the rectum. An ounce of this preparation is said to represent 
the concentrated pure juice of two pounds of the best lean beef or 
the condensed essence of three fourths of a pint of natural expressed 
beef juice. Among other ingredients it contains haemoglobin and 
some albumin. It keeps well in all climates when tightly corked. 
It should not be diluted with hot water, strong liquors, or acid medi- 
cines, as these substances alter it and lessen its value. It may be 
given in champagne and in tea which is not too hot. 

Bovinine is the concentrated expressed juice of raw lean beef ob- 
tained without use of heat or acid. It is claimed that each ounce 
represents nearly one pound of beef, that it contains 26 per cent 
of coagulable albumin, and that it keeps well without decomposition 
owing to the addition of glycerin and alcohol. It is said to contain 
Ggg albumin also. It may be given per os in doses of a teaspoonful 
or more, or in ounce doses with pancreatin for rectal injection. Not 
being predigested, it may be pancreatinised like milk just before its 
administration in cases where it is desirable to give absolute rest to 
an irritable or ulcerated stomach. 

Bovinine has been used topically for injection around indolent 
ulcers with the idea of improving local nutrition, but it is doubtful 
whether this procedure is of any value. 

Beef Peptones. — There are innumerable fluid preparations of pep- 
tonised beef which are recommended for invalid consumption ; but, 
as a rule, they are not so good as those which are freshly made by 
the addition of pancreatin powder, although their use saves time and 
trouble. They may be sometimes employed to tide over an emer- 
gency after a severe operation or collapse from haemorrhage, un- 



n8 



FOODS AND FOOD PREPARATIONS 



controllable emesis, etc. The use of peptones for invalid foods is 
open to the objection that after a short time they excite disgust, 
and may cause vomiting and diarrhoea. The more complete the 
conversion of albumin into peptone the more bitter it becomes. 

Voit, Politzer, Gerlach, and others maintain that true peptone 
possesses little if any nutritive power, and that the albumoses can 
be directly absorbed from the alimentary canal without further fer- 
mentation into peptones. 

Of the numerous commercial preparations sold under the general 
names of peptones, peptonoids, predigested meat extracts, etc., those 
have proved the most nutritious which, in reality, contain the least 
peptone, and the most albumose. 

Bread and beef peptone, or panopeptone, is a preparation in which 
wheat starch and beef are both predigested and preserved in sound 
sherry. It may be taken cold in doses of one to four teaspoonfuls 
iced, or with carbonic-acid water, or wines, but it should not be 
mixed with milk or other foods. Beef peptonoids are also mixed 
with predigested milk and gluten. 

Summary. — Most of these preparations are given in doses of 
one or two tablespoonfuls once in four hours. Usually they are 
tired of soon, and do not support life long, for, beyond the means 
employed of condensation of food by evaporation of water and com- 
pression, it is not possible to " concentrate " nourishment very much. 
Making food assimilable and more useful is another matter from 
concentrating it in the sense that it can be made to support an able- 
bodied man and supply him with energy for a day's work, for ex- 
ample, of mountain climbing. 

Neither does such predigested aliment represent concentration 
for an invalid ; the bulk of food given is certainly reduced, and its 
assimilation may be improved, but it does not convey into the body 
any phenomenal quantity of latent force units or of heat units. It 
is important to understand this fact ; otherwise serious misconcep- 
tions arise as to the actual amount of nutrition which a patient fed 
exclusively on peptonoids and similar food preparations is receiving. 

The following analyses illustrate the comparative composition of 
some of the preceding preparations as given by Chester : 

Composition of Meat Extracts 
(Albert H. Chester.) 





Water. 


Organic 
matter. 


Ash. 


Soluble 
albumin. 


Alcoholic 
extract. 




18.27 
40.65 
37. CO 
41 .20 

54-40 


58.48 

39-35 
55-65 
50.40 
31.84 


23-25 
19.50 

7-35 
8.40 

13-75 


O.05 
LIT 
I.IO 
I.17 
0.44 


44.II 
I3.I8 
10.13 

15-93 
26.32 


Benger's extract of beef 


Johnston's fluid beef 





animal foods u9 

Various Meats 

Beef tongue is a tender form of meat, but it contains rather too 
much fat to agree well with delicate stomachs. 

Veal. — Veal, especially when obtained from animals killed too 
young, is usually tough, pale, dry, and indigestible ; but when the 
animals are slaughtered at the right age the meat is sometimes 
tender, and is regarded by many as nutritious. It differs consider- 
ably from beef in flavour, and contains more gelatin. Veal broth 
is nutritious, and affords a wholesome variety in the dietary for the 
sick. When too much is given it may excite diarrhoea. Veal is 
much more used for invalids in Germany than elsewhere, although it 
figures less conspicuously in hospital dietaries there now than for- 
merly. Bauer declares it to be more digestible than beef, but Pavy 
says, referring to both veal and lamb, " they are meats that it is 
desirable to avoid, generally speaking, in case of dyspepsia," and 
this opinion is prevalent in America as well as in England. Veal 
contains more water and less fat and protein than ox flesh. 

Mutton. — Mutton is rated as more digestible than beef by Eng- 
lish writers upon dietetics. That can hardly be said to be the case 
in this country, where the quality of beef has been so much im- 
proved of late years, and where average mutton is not so tender as 
in England. For example, Balfour writes in his work upon the 
Senile Heart (1894) : " We also recommend meat with short fibre, 
such as chicken, rabbit, game, mutton, or well-grown lamb, in prefer- 
ence to such meats as beef, whose fibres are long and tough." Fat 
mutton is richer in fat than beef, and is certainly less digestible than 
lean beef. 

Undoubtedly tough mutton is quite as difficult of digestion as 
tough beef, and it is harder to obtain it tender. Mutton fat contains 
a larger percentage of stearic acid, which makes it firmer and less 
digestible than beef fat. Fat mutton is more likely to disagree with 
those whose digestion is enfeebled. When properly assimilated after 
digestion, mutton possesses equal nutrient value with beef. 

Mutton should not be eaten until the sheep is at least three years 
old, and the best English mutton is obtained from animals which are 
six years of age. Mutton broth is wholesome and suitable for the 
sick. It may be given in typhoid and other fevers. It is somewhat 
constipating. 

Lamb. — Lamb, when very tender and of just the right age, is 
quite as digestible as beef or mutton, but the flesh contains too large 
a proportion of fat — more than is present in veal. Good lamb is ex- 
pensive, and, on account of the uncertainty of the character of the 
meat, it is not usually to be recommended for invalids. 

Venison. — Venison is a tender meat with short fibres, which is 
very digestible when obtained from young deer, but it is regarded as 



120 FOODS AND FOOD PREPARATIONS 

somewhat stimulating to the stomach, and it is often eaten when 
aged to a degree which, while some think it improves the flavour, 
unfits it for dyspeptics. The meat corresponds very closely in chemi- 
cal composition to lean beef. 

Pork is a tender-fibred meat, but it is notoriously indigestible 
on account of the high percentage of fat present, which may exceed 
37 per cent, or considerably more than the quantity of its nitro- 
genous material. Pork ribs may have as much as 42 per cent of fat. 
The fat is composed chiefly of palmitic and oleic glycerides. 

Ham and Bacon. — Bacon is much more digestible than pork, and 
ham occupies an intermediate position. " On an average, 100 
grammes of ham give 30 of albuminates and 32 of fat ; the salt ranges 
between 7 and 10 per cent " (Bauer). 

In Germany, and especially at Carlsbad and other mineral springs, 
ham- is much prescribed in invalid dietaries. It is often given 
scraped or " rasped." Bauer says (Dietary of the Sick, p. 91) : " The 
flesh of the hog seems to be better adapted for smoking than that 
of other animals, and long experience compels us to recognise 
smoked ham as one of the wholesomest forms of meat. Whether 
boiled or eaten raw, it seems, as a rule, to be more easily digested 
by weak organs than almost any other." An opposite view is preva- 
lent in England and America, where it is less used for the sick. So 
distinguished a dietitian as Pavy omits mention of it in his book 
upon Food and Dietetics. Ham is much more digestible when thor- 
oughly boiled, cut thin, and eaten cold. It should not be fried for 
invalids. Hot ham fat is very indigestible. 

If cut thin and cooked crisp, fat bacon is friable and easily 
broken into small particles during digestion. It can often be eaten 
by dyspeptics, and forms an excellent variety of fatty food for con- 
sumptives. According to Letheby, prime bacon should not lose 
over one tenth of its weight by boiling, and ham should lose less. 
It furnishes ample body heat, and is a valuable ingredient of the 
army emergency ration. In the ordinary ration of armies or in- 
stitutions it proves less monotonous than corned beef or boiled 
beef. Besides its food value, its presence in the ration makes it 
possible to use various foods which could not otherwise be as easily 
cooked. When our troops in the Philippines were deprived of bacon 
in their ration, it was found that they were spending their wages to 
buy lard for frying. 

Horseflesh is a nutritious meat for those who are not fastidious. 
It is consumed in large quantities by the poor in France (where over 
5,000 tons are eaten annually in Paris alone), and to some extent 
in Denmark, Sweden, Germany, and Austria. It has never found 
favour in England or the United States, and most of the horse- 
flesh butchered in this country is canned for consumption by for- 
eigners. 



ANIMAL FOODS 121 

Rabbit has white meat, and Belgian hare meat is partially white, 
but they are not proper invalid foods. 

Fowl. — Chicken is among the most digestible of meats for inva- 
lids, whether cooked by broiling, roasting, or boiling. The white 
meat is more easily digested than the dark, although it differs but 
slightly in chemical composition. Dark meat contains more ex- 
tractives and a little more nitrogenous material than white meat. The 
breast of chicken may be given to a typhoid convalescent or a patient 
recovering from any severe illness before beef and mutton are 
allowed. Chicken broth is almost universally liked, and when 
thickened with rice, and sometimes with an egg, it forms a highly 
desirable invalid food. 

Turkey and capon are somewhat less digestible than chicken, the 
meat being of tougher fibre. 

Young pigeons are quite digestible, and the breast of a squab may 
be given to a convalescent from fever before other meat is allowed. 

Tame ducks and geese are indigestible unless quite young and 
tender, on account of containing too much fat. Goose meat may 
sometimes hold over 40 per cent of fat, with which it is thoroughly 
infiltrated. 

Game, such as the flesh of partridge, grouse, woodcock, snipe, 
prairie chicken, etc., is by many persons preferred when it is " high " 
— that is, when it has been kept long enough for putrefactive changes 
to occur. These may originate in the meat itself or in the viscera 
which have not been removed and from which the odour and flavour 
of commencing putrefaction are derived, and penetrate the meat. 
When the meat itself is not perfectly fresh it may produce violent 
gastro-intestinal disorder, but many persons with good digestive 
organs are not disturbed by the consumption of such food in modera- 
tion, provided it is well cooked. The process of cooking disinfects 
it by heat. The fat of old birds is too strongly flavoured, and their 
meat is tough. Young birds are digestible if properly cooked. 

Animal Viscera. — Animal viscera are eaten to some extent in this 
country, and some of them are digestible, although none are as nutri- 
tious as good meat, and they contain but little nitrogen. With the 
exception of sweetbread, and in some cases the thyroid gland, they 
should not be given to the sick. 

Sweetbread is most useful in the invalid dietary. It consists of the 
pancreas of the calf, called by butchers " stomach sweetbread " to 
distinguish it from the thymus gland of the same animal, called also 
the " neck " or " throat sweetbread." Either gland is tender and 
digestible, the thymus somewhat more so than the pancreas, which 
has larger, more " stringy " blood vessels. 

The thyroid gland has been lately shown to possess remarkable 
power in regulating disordered nutrition in cases of myxcedema, 
chronic skin diseases, etc. It is usually given as a powdered extract 



122 FOODS AND FOOD PREPARATIONS 

in five-grain doses, but it is sometimes cooked fresh and eaten as a 
food. 

Tripe, made from the third stomach of the cow, when tender and 
well cooked, is easy to digest, although somewhat too fat. It con- 
tains about 1 6 per cent of fat and 13 per cent of albuminoids — 
rather more than most viscera. 

The heart is sometimes eaten, but the meat is tough and unde- 
sirable. 

Liver and kidneys are eaten more than any other viscera. If 
cooked too long they become very hard and tough. Calf's liver is 
always better flavoured and more tender if the animal has had fresh 
milk for food and not boiled skimmed milk and slops. Tender liver 
is more easily digested than kidney, and is fairly nutritious. It 
should not be allowed diabetics. These foods are often fried or 
stewed in rich sauces or " devilled," all of which are indigestible 
modes of cooking. 

Brains are fairly digestible, but not nutritious ; they contain too 
much fat and cholesterin for invalids. 

Blood has sometimes been used as a fluid food. At one time 
there was a fashion among consumptives of going to the abattoirs 
to drink it warm, in the belief that it had some specific curative 
value for tuberculosis. This, however, is not the case, and it 
nauseates most persons to taste it, if not to look at it. 

Isinglass— Gelatin 

Isinglass is derived from the membrane of the swimming blad- 
der of the sturgeon, but that of other fishes is occasionally used. 
It is not very soluble in the crude state, but is hygroscopic and 
swells very much in cold water. It dissolves in boiling water, and 
when the water is evaporated again hardens. 

Gelatin. — Gelatin is a substance the potential energy of which 
is calculated as being even more than that of some fats and albu- 
minates, yet in the body it is very inferior in the production of force. 
It is obtained from bones, ligaments, and other connective tissues. 

It is a curious and interesting property of gelatin that used alone 
it fails to have much nutritive power, but in proper combination 
with other foods it is a useful aliment. " By the addition of gelatin 
very large quantities of albumin can be spared in the body or devoted 
to increase of bulk, just as by the supply of fats and carbohydrates " 
(Bauer). 

Gelatin itself takes no part in repair and growth of tissues — it 
must be regarded solely as an " albumin-sparer." It cannot, there- 
fore, replace albumin, the loss of which still goes on to some ex- 
tent even when gelatin is eaten in large quantity. It also slightly 
spares the consumption of non-nitrogenous materials. This is a 



ANIMAL FOODS 123 

question of considerable importance in the feeding of invalids, be- 
cause, while many jellies are easily digested and are agreeable to the 
palate, it is useless to burden the stomach with them if they do not 
possess nutritive properties in proportion to other foods, and the 
matter must therefore be discussed somewhat in detail. The " Bone 
Soup Commission " of the French Academy of Sciences was consti- 
tuted to determine the nutritive value of prolonged boiling of bones 
in order to obtain, if possible, an inexpensive form of aliment for 
hospital patients. The commission made elaborate researches, the 
result of which showed that animals which were fed exclusively upon 
gelatin rapidly deteriorated in strength and weight, and finally suc- 
cumbed to starvation. Subsequent experiments upon gelatin have 
been conducted by many physiologists with these conclusions: 1. 
Gelatin is innocuous, and its exclusive use will not support life. 2. 
Mixed with other foods, it promotes nutrition and is easily digested 
and absorbed. 3. To some extent it saves waste of albuminous 
tissues. 

Since bones consist of nearly two thirds of their weight of gela- 
tin, the latter may be advantageously used as an inexpensive 
means for furnishing variety in the diet by addition to meat broths 
and jellies, pea and bean soups, etc. M. Edwards says that the 
proper proportion for such mixtures should be at least one fourth 
of meat soup to three fourths of gelatin soup. The bones them- 
selves may be broken and made to yield fat and gelatin for soup 
" stock." The amount of nourishment which they afford is ex- 
tremely little, and they are mainly of service for economic reasons 
to save waste. 

Edible birds' nests are not true gelatin, but a Chinese food 
product allied to mucin. 

Gelatinous substance may be obtained from boiling for several 
consecutive hours such material as calves' feet, sheep's trotters, ox 
tails, etc., and after clarifying, straining, and concentrating, very 
palatable jellies may be made, to which chicken or mutton is added 
for invalid use. 

Calf's-foot jelly and calf's-head jelly, if not made too rich by added 
ingredients, make suitable invalid dishes, especially when flavoured 
with sherry or Rhine wine. Ox-tail soup is too rich for the sick. 

Pure white gelatin is insipid, and is almost impossible to eat in 
considerable quantity unless it is well seasoned. If free from all 
gluey taste and odour, and prepared with coffee or lemon juice, or 
other fruit flavours, it makes an easily digested invalid food. Or it 
may be combined with eggs or milk as blancmange, or with soup. 
The addition of meat extracts to it improves the taste, and the ad- 
mixture of wine, like good sherry, alters the taste rather by the in- 
troduction of its aromatic principles than by the alcohol itself, which 
is largely evaporated from the jelly. 



124 FOODS AND FOOD PREPARATIONS 

" Well-prepared jellies, not containing too much acid or pungent 
spices, are very useful foods for invalids, and may be administered 
with advantage in febrile states " (Bauer). 

Dry gelatin contains 17.3 per cent of nitrogen, which is even a 
larger proportion than is contained in albumin; consequently urea 
excretion is decidedly increased by gelatin feeding. Diuresis is 
also produced, and the desire for liquid is intensified, so that a large 
proportion of gelatin in the diet causes decided physiological effects. 



Fish 

Fish vary both in digestibility and nutritive qualities. The chief 
differences are in regard to coarseness of fibre and the quantity of 
fat present. Fish meat is less stimulating, sustaining, and satisfying 
than that of birds or mammals. 

Eels contain the largest proportion of fat, which amounts to 28 
per cent. Herring have 7, salmon about 6.5, while sole has but 0.25 
per cent (Konig). Mackerel, trout, and shad have considerable fat. 

Fish which, like the salmon, are rich in flavour and in fat, while 
they may be very nutritious, are much less easy of digestion than are 
the simpler varieties, such as sole or flounders and codfish. Dried 
codfish can be eaten on long sea voyages day after day without the 
repulsion which is soon excited by the continuous diet of the more 
highly flavoured fatty fish. 

The flesh of many fish contains a large percentage of water, be- 
sides gelatin. 

The following fish, in the order named by Walker, have the 
largest percentage of albuminoids : Red snapper, whitefish, brook 
trout, salmon, bluefish, shad, eels, mackerel, halibut, haddock, lake 
trout, striped bass, cod, flounder. 

All fish are best in their proper season, for out of season they 
deteriorate from change in food or other causes, and are less nutri- 
tious, besides possessing inferior flavour, and sometimes disagreeable 
odour. They should be eaten as fresh as possible, for there are few 
alimentary substances capable of exciting so violent gastro-intestinal 
disturbance as decomposing fish. The practice of preserving fish 
frozen or packed in ice is open to the objection that the cold pre- 
vents malodours from revealing commencing putrefaction. Vivid 
red gills and fulness and brightness of the eye are a good test of 
freshness. 

It is a popular fallacy that fish constitute a good " brain food " 
on account of their containing a large percentage of phosphorus, a 
prominent ingredient of nerve tissue ; but in reality many fish con- 
tain less of this element than meat, and neither Eskimos nor other 
aboriginal tribes who live largely upon fish are noted for intellec- 
tuality. 



ANIMAL FOODS 125 

Some fish contain different species of tapeworm, but they are 
seldom if ever transmitted to man. 

Fish having white meat constitute an excellent food for invalid 
diet, and when cooked by boiling or broiling (not frying) they may 
be given to convalescents and to those with feeble gastric powers. 

The most digestible fish are fresh sole, whiting, bluefish, white- 
fish, bass, red snapper, fresh codfish, halibut, shad, and smelt. Pavy 
says : " Of all fish, the whiting may be regarded as the most delicate, 
tender, easy of digestion, and least likely to disagree with a weak 
stomach. The haddock is somewhat closely allied, but has a firmer 
texture and is inferior in flavour and digestibility." 

Crimping is a process sometimes applied to fresh fish, like the cod, 
by which the firmness of the flesh, as well as its flavour, is increased. 
As soon as caught, the fish is incised transversely by numerous deep 
cuts. On being plunged into ice-cold water, the muscle fibres con- 
tract firmly and so remain. 

As a rule, dried, smoked, or pickled fish should not be given to 
invalids, although thoroughly boned and desiccated or " shredded " 
codfish is quite tender. The latter process is now conducted by ma- 
chinery, and thus prepared the fish requires less prolonged soaking 
and cooking. 

Fish roe is not very nutritious, and it serves mainly as a relish. 
Shad roe, thoroughly cooked, is not objectionable, but sturgeon's 
roe or caviare, which is sometimes used as an " appetiser," is capable 
of arresting digestion, especially when old, black, or rancid. Caviare 
contains, according to analyses by Konig and Brimmer, water, 45.05 ; 
proteids, 31.90; fat, 14.14; salts, 8.91 per cent. 

It must not be forgotten that some persons cannot digest fish of 
any kind, or at most can take but one or two varieties without pro- 
voking an attack of dyspepsia or biliousness. A few tropical fish are 
poisonous, and constitute an exception to the general edibility of 
vertebrate animals. (See Fish Poisoning.) 

There are no diseases in which a fish diet possesses specific 
value, but often in chronic Bright's disease, lithsemia, gout, or 
other conditions in which it is undesirable to give much meat, 
it is very serviceable as a compromise. 

Crustaceans 

Lobsters, crabs, and shrimps, although they constitute a whole- 
some food, when absolutely fresh, for those in health, should never 
be admitted to an invalid dietary. They are all scavengers of the 
sea, and crabs not thoroughly cleaned or imperfectly cooked may be 
poisonous from contamination with putrid matter, although their 
own flesh is good. Soft-shell crabs are by no means always " soft " 
when eaten, and their shells furnish a large bulk of indigestible res- 



126 FOODS AND FOOD PREPARATIONS 

idue, which may prove irritating. I recall one fatal case of appendi- 
citis caused by them. 

Lobsters are highly poisonous to some persons even when fresh, 
and especially if eaten with other food they may excite nausea, 
vomiting, and even gastro-enteritis. In others they may cause urti- 
caria or aggravate existing skin eruptions. 

Persons who live at a distance from the seashore are apt, in 
making occasional visits to seaside resorts, to gratify a fondness for 
crustaceans, fish, and shellfish food by an excessive indulgence in 
" shore dinners," which result disastrously with stomachs unaccus- 
tomed to such diet ; but the evil effects are fortunately temporary. 

Shellfish 

Oysters, clams, and mussels are very nutritious food, and the for- 
mer at least, when fresh and when eaten raw or properly cooked, 
are an excellent invalid aliment. Oysters can often be digested 
earlier than meat in convalescence from fevers, and in many forms 
of gastric disorder. 

The " soft part " of shellfish is formed chiefly by the bulkier 
liver, while the tough, harder portion is mainly the muscle which 
attaches the animal to its shell. This muscle is coagulated and 
rendered tougher by all forms of cooking; hence raw oysters are 
more tender and digestible than if stewed or broiled. In oysters the 
liver is relatively larger and more nutritious than in clams. In rec- 
ommending oysters to invalids it is always best to allow only the 
soft parts to be eaten, and when this rule is observed they may be 
cooked in a variety of ways — by stewing, broiling, roasting, or " pan- 
ning," and steaming — but they should never be fried for the sick. 

Both oysters and clams have the advantage that they are very 
generally liked, and they make a pleasant variety of food to relieve 
restricted diets. They impart an agreeable flavour to milk and 
broths. It is customary to forbid their use by diabetics, on the 
ground that their livers contain glycogen. Clam juice or plain clam 
broth is almost specific for some forms of vomiting, especially sea- 
sickness. It may be tried in the vomiting of pregnancy, and may be 
retained when beef juice and milk are not. It is mildly stimulating 
to the gastric mucous membrane, and slightly nutritious and laxative. 
It is best obtained fresh, but very good canned or bottled prepara- 
tions of it are made which keep pure indefinitely. It may be taken 
either hot or cold with a little Cayenne pepper half an hour before a 
meal. It seems to have an invigorating effect upon the stomach, 
and promotes the appetite. 

Mussels are less commonly eaten in this country than in England 
and some parts of Europe. They belong in the same category with 
oysters and clams, and the remarks just made in regard to the latter 



VEGETABLE FOODS 127 

apply to them as well. There is a form of poisoning by mussels 
which is exceedingly dangerous and sometimes fatal. (See Poison- 
ing by Shellfish.) 

In some persons shellfish, like crustaceans, produce skin erup- 
tions, such as urticaria, or aggravate existing eczema. 



IV. VEGETABLE FOODS 

Sugars 

Sugars are crystallisable carbohydrates in which oxygen and 
hydrogen exist in proportion to form water. There are many vari- 
eties, of which the commoner contained in food or used as an adjunct 
to diet are cane sugar, saccharose or sucrose, grape sugar, dextrose 
or glucose, levulose or fruit sugar, and sugar of milk or lactose. 
Inosite, mannite, dextrin, sugar of malt or maltose, honey, a sweet 
nitrogenous substance called saccharin, and fruit sugar or levulose 
(diabetin) are also used. Sugar may be derived from the stems of 
plants, as in the case of the sugar cane, or the palm, from tubers like 
the beet, from maple-tree sap, and from other vegetable growths. 

The sugars present slight differences in their physical properties, 
such as specific gravity, solubility, and effect upon polarised light. 
They also differ in sweetness of taste and in digestibility. 

As foods, sugars have essentially the same uses as starches (see 
Farinaceous Foods, p. 134), for all starch must be converted into 
dextrin or sugar before it can be assimilated. For this very reason, 
sugars, although they form an excellent class of food, producing 
force and heat and fattening the body, are not absolutely necessary 
for the maintenance of health if starches or fats are eaten. Recent 
experiments in the German, British, and other armies show that a 
liberal allowance of sugars in the diet tends, during manoeuvres, to 
maintain strength, lessen hunger and thirst, and lessen the liability to 
heat exhaustion. 

They possess additional properties, in that they have a more 
agreeable flavour than starches, are more satisfying to the palate, 
and they have antiseptic and preservative power. Hence sugars and 
sirups are extensively employed to preserve fruits either in solution 
or in dried form, like " candied " cherries, ginger, etc. 

When taken for food, sugar is quickly soluble, and on this account 
taxes the digestive organs but little. Cane sugar, however, needs to 
be converted into grape sugar before it can be absorbed and assimi- 
lated, and grape sugar, which needs no change, is therefore some- 
times spoken of as a predigested carbohydrate. 

Between seven and eight million tons of sugar are consumed each 
year in the world at large. The English-speaking nations are the 
largest consumers. In 1895 the per capita consumption in England 



128 FOODS AND FOOD PREPARATIONS 

was 86 pounds as against 30 pounds in Germany, France, and Hol- 
land, and 7 pounds in Italy, Greece, and Turkey (Mary Hinman 
Abel). Cane sugar was originally used exclusively in preparation of 
medicines, not as a food. 

Many persons acquire an inordinate fondness for sugar, and con- 
tinued overindulgence in this food is very sure to give rise to 
flatulent dyspepsia, constipation, and disorders of assimilation and 
nutrition. It may even cause functional glycosuria. (See Dia- 
betes.) 

Sugar is very fattening. In the West Indies the negroes always 
grow fat in the sugar season, when they chew the cane in the 
fields. 

Sugars are emphatically force producers.* Chauveau and Kauf- 
mann have demonstrated that during muscular activity the consump- 
tion of sugar in the body is increased fourfold. If one pound of 
sugar were burned so as to utilise all the heat, it would raise five 
gallons of water from the freezing to the boiling point (A. C. 
True). 

Harley found experimentally that the muscle-energy producing 
effect of sugar is so great that two hundred grammes (seven ounces) 
added to a small meal increased the total amount of work done from 
6 to 30 per cent, and that when sugar was added to a large meal it 
increased this total from 8 to 16 per cent. 

Sugars and the Urine. — Grape sugar and fruit sugar or levulose, 
when eaten in large quantity in health, reappear unaltered in the 
urine, but the latter sugar in diabetes is said by Moritz to be con- 
sumed within the body. Sugar eaten in excess with other food 
increases the quantity of urine and feces and the urea elimination 
(W. G. Morgan). 

Saccharose, eaten in excess, may reappear in the urine unaltered, 
or more commonly as glucose. 

Lactose is converted into glucose, and it produces functional gly- 
cosuria more easily than the latter if eaten in bulk. 

Alimentary glycosuria usually ceases in a few hours after discon- 
tinuance of eating the food which has caused it. 

There are some diseases in which sugar in all forms should be 
strictly avoided, such as flatulent dyspepsia, acute and chronic gas- 
tritis, gastric dilatation, gout, rheumatism, obesity, and the uric- 
acid diathesis, and it should be absolutely forbidden in diabetes. 
Temporary disturbances of digestion from eating too much sweet 
food are very common, and can usually be rectified by simple reme- 
dies, and by withholding or diminishing the customary allowance of 
sugar. Sugar eaten constantly in excess spoils the teeth and de- 
stroys the appetite for other food. It lessens the hydrochloric acid 
of the gastric juice in cases of hyperchlorhydria, and is said to dis- 
solve mucus. 



VEGETABLE FOODS 1 29 

Cane Sugar. — Cane sugar, saccharose, or sucrose, as used in 
the United States, is usually derived from the clarified and crys- 
tallised juices of the sugar cane (saccharum ofhcinarum) , but it is also 
made from beet root, as originally discovered by Marggraf, of Berlin, 
in 1747. The latter form is somewhat less sweet than are the better 
grades of cane sugar. The root contains 12 to 15 per cent of sugar. 
One third the world's commercial sugar is derived from sugar cane, 
and two thirds from beets. The annual per capita consumption of 
sugar in the United States is 66 pounds. About one quarter of 
a pound per diem may be eaten without harm. Much more than 
this in a short time is liable to disorder digestion, just as do the 
equally diffusible peptones eaten in excess. 

Mary Hinman Abel, in an exhaustive study of the food value of 
sugar, says : 

" There is no proof that sugar is harmful to the teeth, although 
doubtless sweet food, allow r ed to cling to the teeth after eating, 
rapidly ferments, and acids will be formed that, according to Pro- 
fessor Miller, of Berlin, may attack the teeth. This is equally true 
of starchy foods. It is said, however, that the negroes of the 
West Indies, who consume enormous quantities of sugar, have 
the finest teeth in the world. It is also unproved that sugar pro- 
duces gout." 

Sugar is better digested in proportion to the amount of exercise 
taken. 

The maple tree yields from 2 to 10 per cent of sucrose. Maple 
sugar is eaten chiefly as a luxury, on account of its unique and 
agreeable flavour. It also makes an excellent sirup which is in 
great demand. About 7,500,000 pounds of maple sugar are made 
annually in the United States. Cane sugar can be obtained from 
the sugar pea, from the flower buds of the coca palm, and from 
other substances. It is soluble in half its weight of cold water and 
in less hot water. 

The sap which is drawn from the sugar cane as well as the juice 
of compressed beet root is not a pure aqueous solution of sugar, but 
is mingled with other materials, chiefly of a mucilaginous character. 
An elaborate process of refining is applied in order to produce the 
commercial white sugars of various grades. The principal steps in 
this process are as follows: " 1, Melting of the sugar; 2, straining 
through bag filters ; 3, filtering through charcoal ; 4, boiling or 
evaporating the decolourised liquid in vacuum pans ; 5, separation 
of crystallised sugar by centrifugals " (Clark). The process is so 
cheap that cane sugar is practically never adulterated. 

Cane sugar was formerly sold more extensively than at present 
in the form of coarse brown sugar. This variety is somewhat im- 
pure, and on this account has a slightly laxative action ; but the' 
great improvements made of late years in the processes of refining 



130 FOODS AND FOOD PREPARATIONS 

sugar, and the extreme cheapness of this commodity, place the 
clarified forms of it within the reach of all, and even reduce to a 
minimum the temptation for sophistication which was originally 
much more extensively practised, especially in the adulteration of 
confectionery, with chalk, plaster of Paris, etc. 

The most highly refined cane sugars contain about 0.25 per cent 
only of impurities and ash, but poorer grades hold 1 to 2.3 per cent, 
with as much water (Konig). Cane sugar is about two and a half 
times sweeter than glucose. Cane sugar is completely digested and 
absorbed, leaving no fecal residue. 

" Grocer's itch " is a form of irritation of the skin of the hands 
sometimes acquired from contact with moist brown sugar, adulter- 
ated with dirt or sand and mites. 

Caramel. — By the application of heat, at 400 F., refined cane 
sugar is melted, browned, and converted into a non-crystallisable 
fluid substance called caramel, having a slightly bitter but agree- 
able taste. Comparatively insipid farinaceous food, such as corn- 
starch and farina, may be flavoured with it for invalid diet. Burned 
flour may be used in the same manner, but its flavour is less agreea- 
ble. Caramel is also useful for flavouring milk, custards, etc. 

At 320 F. sugar melts to an amber fluid, which, on cooling, is 
brittle and transparent. In this form it is called " barley sugar," and 
is much used in confectionery. 

When sugar is cooked with acid fruits it is partly converted by the 
heat and acid to less sweet substances, hence to sweeten cooked 
fruits the sugar should be added when the cooking is completed. 

Sugar differs from starch by containing another molecule of 
water. Starch, which forms fully three fourths by weight of the 
solid ingredients of wheat flour, is altered into sugar by heating with 
a little sulphuric acid, or even by prolonged heating alone or " torri- 
fication." The latter process converts it into dextrin, sometimes 
called " British gum," on account of its substitution in commerce 
for gum arabic. With prolonged heat there is a further change in 
the starch, which becomes of a brownish and finally black hue, pass- 
ing through a stage analogous to the formation of caramel from 
sugar, and with extreme heat forming a residue of black carbon, all 
the water having been driven off. A hard, dried, thoroughly 
browned bread crust or toast is therefore similar to caramel, and 
every one is familiar with its gain in flavour. 

Sugar candy is made by extremely slow crystallisation. 

Sorghum is a variety of grass or cane from which sugar can be 
extracted, but in this country it is used more for the manufacture of 
molasses. 

Candy and Confectionery. — Candy contains from 75 to 90 per cent 
of sugar, to which may be variously added butter or other fats, nuts, 
fruits, starch, glucose, flavouring extracts. Cheap varieties are 



VEGETABLE FOODS 131 

coloured with aniline dyes, and are composed largely of glucose 
and starch. Children assimilate candy better than adults because 
they are less liable to dyspepsia, and because of their relatively 
active muscular energy and relatively large body surface for losing 
heat, in proportion to their size. They do not, as a rule, care for 
fat meat, and prefer sweets as a natural substitute. 

An infant taking two quarts of milk per diem consumes nearly 
three ounces of sugar in the form of lactose. In later childhood the 
ability to digest starches replaces to some extent the need for sugar. 
It is, however, important that the taste for candy and sugar common 
to all children should not be permitted to interfere with a wholesome 
and natural appetite for other foods, especially fresh vegetables and 
fruits. The value of sweets in the adult dietary has of late years 
found recognition in armies. The British War Office shipped 
1,500,000 pounds of jam to South Africa as a four months' supply for 
116,000 troops, and one New York firm during the Spanish-Amer- 
ican War shipped over fifty tons of confectionery to the troops in 
Cuba, Porto Rico, and the Philippines. The confectionery consisted 
of chocolate creams, cocoanut macaroons, lemon and other acid fruit 
drops. 

Molasses, Treacle, and Sirup. — Molasses and treacle are products 
incidentally formed in the process of crystallising and purifying cane 
sugar. Treacle is the waste drained from moulds used in the refin- 
ing process, and it contains, besides sugar, acids, extractives, salts, 
and more or less dirt. Like cane sugar, molasses constitutes a 
very desirable food, and is highly nutritious. Its use, both for cook- 
ing and to add to farinaceous food and enhance its flavour, is too 
well known to require description. Molasses, according to Konig, 
contains acetic and formic acids, which impart their feaction to it. 
It also contains cane sugar and 30 per cent each of invert sugar and 
of water. 

Both treacle and molasses, owing to impurities, are more laxa- 
tive than refined sirup, and the effect, as an aperient, of plain ginger- 
bread made with good brown molasses is due to this property. For 
young children from six to ten years of age molasses sometimes 
operates very well in keeping the bowels open. 

Plain molasses candy is a wholesome form in which to give sugar 
to growing children, if they are not allowed to eat too much and 
spoil their appetite for other foods. It is mildly laxative. Walker 
says that " good candy is good food." Candies are often made too 
rich with butter, chocolate, and other ingredients, when they dis- 
agree. 

Molasses, like sirup, is a good preservative. It has been used to 
preserve potatoes in layers. An old-time custom among soldiers in 
the field is to fill a canteen with two parts vinegar and one part 
molasses as an emergency sustaining drink. 



I32 FOODS AND FOOD PREPARATIONS 

G-lucose. — Grape sugar is present in almost all fruits, in the 
sweeter varieties of which it exists in large quantity. In peaches, 
pineapples, and strawberries it is found with cane sugar, and in 
grapes, cherries, and honey it occurs in connection with other varie- 
ties of sugars. . In dried fruits, such as raisins or figs, glucose is 
present in a gummy form. It is commonly manufactured from 
starch. 

Although prepared for immediate absorption from the stomach 
and intestine and assimilation, glucose is of little service for fla- 
vouring other articles of food, for when so used it is apt to produce 
flatulent dyspepsia with acid eructations. Moreover, it has less 
strength of sweetness than cane sugar, and, as it is more difficult 
to crystallise, it is much less convenient and desirable for gen- 
eral use. 

Sucrose and maltose can only be absorbed by alteration into glu- 
cose. If glucose be eaten as a food, in form of candy or otherwise, 
it overloads the system by being too promptly absorbed. Malt ex- 
tracts, sirups, and preserves adulterated with glucose easily ferment, 
for nothing ferments more promptly than such combinations with 
the bacteria present in the stomach. 

Lactose. — Lactose, or sugar of milk, is taken as a food in some 
quantity with ordinary milk, and forms a very important ingredient 
of the diet of the growing infant, who is unable to digest much 
starch during the first year of life, and yet requires an easily 
assimilable form of carbohydrate. Cow's as compared with human 
milk is deficient in lactose, and the latter should therefore be added 
in proper proportion to the milk of bottle-fed infants. (See Milk 
Composition, p. 52.) It might be used for sweetening various arti- 
cles of food, but it possesses no advantages over ordinary cane 
sugar, and is in fact more expensive and less sweet. It is mildly 
diuretic. 

Mannite. — Mannite is obtained from the sweet juice of the stems 
of the ash tree. It is also contained in beet roots and some other 
vegetables. Like sucrose, it crystallises, and is white and free 
from odour. It does not ferment with yeast. It is laxative, and 
it may be used in diabetes, for it is not secreted in the urine as 
glucose. 

Levulose. — Fruit sugar, or levulose, is now sold under the name 
of diabetin, in crystalline form, for use in diabetes, on the ground 
that it is not known to reappear in the urine. It can be taken freely 
and in considerable quantity without disordering digestion, as sac- 
charin often does after continued use. Diabetin is sweeter than cane 
sugar, and has a somewhat fruity taste. 

Honey. — Honey is a form of sugar prepared from the cane sugar 
of various flowering plants gathered by bees, which convert it by 
hydrolysis chiefly into dextrose. They then store it in cells. Thus 



PLATE III. 




'£®S 



V- 




K* 



Q i 






r "* 



WHEAT 






# fe 



*fc> 




"1 




RYE 



OATS 



&^*; 




CORN 



#i#^^ 






RICE 



STARCH GRANULES, MAGNIFIED. 

(From Bulletin .Vo. 13, Division of Chemistry, United States Agricultural Burma' 



liltA \\ \ 1(1 liKO. MARX. 



VEGETABLE FOODS 1 33 

it is really a vegetable product, although manufactured by an insect. 
In addition to sugar, it holds several other ingredients, principally 
wax, gum, pigment, and odorous materials. The sugar exists in 
two forms — crystallisable and non-crystallisable. The former is 
somewhat similar to glucose. 

Honey contains, according to Konig: Water, 16.13; dextrose, 
78.74; cane sugar, 2.69; nitrogenous matter, 1.29; ash, 0.12 per cent, 
besides traces of other ingredients. 

Honey was more in demand for sweetening before the discovery 
of a method of making sugar from the sugar cane. It is a whole- 
some food, and is fattening when eaten with bread. In some coun- 
tries — as, for example, in the Black Forest of Baden — the peasants 
consume it as a staple article of diet. Artificial honeycombs are 
now made from paraffin, stamped into cells to imitate the original, 
which enables the bees to devote more energy to the manufacture of 
honey and bestow less on the combs. 

In a few instances, fortunately very rare, honey has proved poi- 
sonous owing to the bees having fed upon poisonous flowers. An 
epidemic of gelsemin poisoning occurred in Branchville, S. C, from 
this cause in which twenty persons were severely affected, three 
of them fatally. 

Saccharin. — Saccharin is a crystallisable organic-acid substance, 
containing, in addition to the elements carbon, hydrogen, and 
oxygen, a little sulphur and nitrogen. It was introduced a few years 
ago as a substitute for sugar, and it is especially useful in cases of 
obesity, rheumatism, gout, and diabetes, when the withdrawal of 
sugar is followed by intense craving for it, or a refusal to eat those 
foods which are customarily flavoured with it. It is antiseptic, and 
has the property of acidifying the urine, being eliminated unaltered 
by the kidneys, hence it can be used medicinally in cases of pyelitis 
or cystitis. It may be given for months at a time without danger, 
if the quantity prescribed does not exceed more than one or two 
grains, three times a day. More than this dose may cause gastric 
derangement. It may be added to food in cooking, or a one-quarter 
grain tablet may be used to sweeten a cup of coffee. 

Cereals and other Starchy Foods 

Starchy Foods in General. — The cereals in commonest use as food 
products are wheat, corn, rice, rye, barley, oats, buckwheat. From 
these are manufactured a variety of flours and meals. 

About 30 per cent of all cereals produced in the world are grown 
in the United States, and at least one fourth of the total wheat pro- 
duction is from this country ; on the other hand, 98 per cent of the 
rye and 75 per cent of the barley and oats are grown in Europe. 
The United States produces about 75 per cent of the corn of the 



134 



FOODS AND FOOD PREPARATIONS 



world. These estimates give a general idea of the relative use of 
these cereals, and illustrate the great preponderance of wheat bread 
and cornmeal and other preparations of corn eaten in the United 
States. 

Besides the cereals and vegetables which, like the potato, are 
composed chiefly of starch, there is a large miscellaneous group of 
starchy foods used as flours, which are therefore conveniently con- 
sidered with the cereals. Such are arrowroot, tapioca, cassava, sago, 
and peas. Peanuts, chestnuts, and plantains are also sometimes used 
to furnish flour. 

Starch is the term applied to the fecula or granular material 
found in fruits, roots, and tubers and in the cellular tissue of plants. 
The structure and form of the starch granules vary, and those from 
different plants may be distinguished by microscopic examination. 

Patients, as a rule, are ignorant as to the nature and limitations 
of " starchy foods," and their conception of them is based upon such 
foods as resemble powdered laundry starch in appearance, like ar- 
rowroot, cornstarch, etc. After being told to eat no starchy foods, 
they not infrequently will say they suppose that potatoes are not 
starchy. The expression at best is not an accurate one ; for many 
starch-holding foods contain a large proportion of other ingredients, 
especially proteids, as will be seen from the following table furnished 
by Riibner : 



Wheat 

Rye 

Barley 

Maize 

Rice 

Buckwheat 



ONE HUNDRED PARTS OF 


DRY MEAL 


CONTAIN — 




Albumin. 


Starch. 


16.52 




56 25 


II.g2 




6O.9I 


17.70 




38.31 


13-^5 




77-74 


7.40 




86.21 


6.8—IO.5 




65-05 



Farinaceous foods are composed of flour of different kinds, and 
constitute a subdivision of starchy foods. The different starchy and 
farinaceous foods are derived from a variety of plant structures, in- 
cluding roots, tubers, bulbs, stems, pith, flowers, seeds, fleshy fruits, 
etc. Some, like the banana and certain vegetables, are eaten raw, 
but the majority require cooking, and the starches derived from 
grain-bearing plants of the grass tribe or cerealia usually must be 
prepared by grinding and milling before cooking. About one sixth 
of the protein of the various grain flours passes through the ali- 
mentary canal undigested. 

The following table by Professor Atwater will be found useful in 
giving at a glance the average percentage of starch contained in the 
commonest vegetable foods : 



VEGETABLE FOODS I 35 

Atwaters Table of the Percentage of Starch in Vegetable Foods 

"Wheat bread 55-51 Potatoes 21.3 

"Wheat flour 75-6 Sweet potatoes 21. 1 



Graham flour 71.8 

Rye flour 78 . 7 

Buckwheat flour 77-6 

Beans 57.4 

Oatmeal 68.1 

Cornmeal 71. o 

Rice 79 . 4 



Turnips 6.9 

Carrots 10 . 1 

Cabbage 6.2 



Apples 14. 3 

Pears 16.3 

Bananas 23.3 



In round numbers it may be stated that starch composes one fifth 
of potatoes, one half of peas, beans, wheat, rye, and oats (their flours 
contain more), and three fourths of rice and Indian corn. 

In addition to the cooking which the cerealia require, they are 
often predigested by diastase for invalid use. Strong heat converts 
starch to dextrin ; but diastase, like the natural digestive ferments, 
can convert it into maltose, and as such it is fitted for absorption. 

Fortified gruels, as they are called by Roberts, are made of cereal 
flours or dried legumes, with addition of milk, beef tea, or eggs. The 
flours if used alone, in strength of 5 per cent, become pasty and taste 
insipid, but if one eighth of their weight of ground malt be added 
they remain fluid with 20 per cent of flour, and, as this starch is 
largely dextrinised, they are highly nutritious. Thus made, Roberts 
says they contain 2 per cent of proteid and 14 per cent of carbo- 
hydrates. 

Bread-making. — It has been well said that the quality of the 
bread used by the inhabitants of any country is a fair measure of 
their civilisation. Flour is prepared from various grains by crushing 
and grinding processes. The grains consist of (1) an outer layer, 
the husk or skin, which is woody, fibrous, and indigestible, and which, 
in the milling process is separated into " bran " ; (2) the kernel 
within the husk, which is composed of gluten, fats, and salts ; (3) the 
starch. 

To appreciate the important details of bread-making, it will be 
necessary to first review the structure and composition of the grain 
from which the bread is derived. 

Structure of the Wheat Kernel. — The wheat kernel is subdivided 
into four layers. The first or outermost layer (Fig. 1, H) consists of 
two or three strata of elongated cells the long diameters of which 
correspond with the long axis of the grain. From these cells slender 
filaments or tapering, hair-like processes project outward. The cell 
margins are irregular in outline, and appear somewhat beaded. 

Immediately beneath the outer hairy layer lies the second layer 

(Fig. 1, F), consisting of more or less quadrangular cells, with 

rounded angles, which are more uniform in size than the others, and 

grow at right angles to them. The third layer (Fig. 1, K) consists 

11 



136 



FOODS AND FOOD PREPARATIONS 




Fig. i. 



of a delicate, transparent membrane-like structure. The fourth or 
internal layer (Fig. I, S) is composed of large, almost rectangular 
cells arranged in one or two strata, and which contain a dark granular 

material which may be easily separated 
from the cell walls. 

The grains of other cereals conform 
in a general way to the structure of the 
wheat grain, although they differ in the 
thickness of the several layers, the num- 
ber of their strata, and the size of the 
individual cells. 

Bran. — Bran (Fig. 2, a) contains car- 
bohydrate material which is but little if 
at all digested in the human alimentary 
canal, although the lower animals derive 
abundant nutrition from it. The nutritive 
salts of wheat are chiefly contained in the 
bran ; and for this reason, if bread con- 
stitutes the principal food for a. time, it is 
best to eat that which contains some bran. 
But if too much is consumed it hastens 
peristalsis, and nutrition suffers because 
the food is hurried out of the alimen- 
tary canal before absorption is complete. 
When bread is eaten with other food con- 
taining nitrogen and salts, white bread is preferable. 

Gluten. — Gluten is separated in the process of making starch 
from wheat and other grains. It is a valuable nitrogenous food 
product, consisting of (a) 60 
to 70 per cent gliadin and (b) 
30 to 40 per cent glutenin. 
The greater part of the glu- 
ten is held in the central four 
fifths of the grain. The glia- 
din adheres to the glutenin, re- 
tains the gas in dough, and in 
excess it makes the flour soft 
and sticky, hence soft wheat 
yields a flour with high per- 
centage of gliadin, but hard 
wheat has a low percentage. 

Gluten is capable of considerable expansion independently of the 
development of C0 2 , and, as this power varies with different flours, 
it affects the quality of lightness of the bread. Some glutens expand 
four or five times as much as others (H. Snyder and L. A. Voor- 
hees). 



Section through wheat 
kernel (from Rupp). H y hair- 
like processes ; F, K, second 
and third layers ; S, fourth 
internal rectangular cell lay- 
er ; a, b, c, d, successive lay- 
ers represented as partially 
stripped off. 




Fig. 2. — Microscopic characters of wheat 
( 4- 200) (from Landois and Stirling), a, cells 
of the bran ; b, cells of thin cuticle ; c, gluten 
cells ; d, starch cells. 



I'LATK IV. 




Maize Starch x 145 




Wheat Starch x 145 
{Prom Bulletin So. IS, Division of Chemistry , United States Agricultural Hurmi 



HICIIAKDSUN. 



VEGETABLE FOODS I 37 

Composition of Bread. — Bread is really a mixed food, in that it 
contains so many classes of ingredients — fat, protein, salts, sugar, 
and starch — and this is probably the explanation of the fact that its 
daily use never cloys the appetite. Although it contains some fat, 
it has not enough for a perfect food, and hence the almost universal 
custom of using butter with it. Moreover, it forms a convenient 
vehicle for taking fat in this manner, and the butter aids in the 
mastication and deglutition of the bread. 

Good bread contains, on the average, protein, 9.57 per cent ; fat, 
1.5 to 2 per cent ; and carbohydrates, 55 per cent, the remainder being 
largely water, with a trace of salts. In round numbers, bread con- 
tains about two thirds nutrient material, or twice as much as beef, 
although it is of different force value in the body. One hundred 
grammes furnish 216 calories. A pound of bread is made from 
about three quarters of a pound of flour by the addition of 25 per 
cent of water. Some flours will take up 10 per cent more water 
(Snyder and Voorhees). 

Bread-baking. — Bread is made from a mixture of the flour of 
any cereal with water, which is added in definite proportion, consti- 
tuting a dough which is made uniform by kneading either by hand 
or by machinery. A small quantity of the ferment yeast is also 
worked uniformly into the dough and the mass is left to stand for a 
number of hours, during which fermentation progresses, producing 
from the starch alcohol, carbonic acid, and water. The best tem- 
perature at which this leavening proceeds is from ioo° to no F. 
After remaining for some hours at a uniform temperature, the bread 
is baked in a hot oven the temperature of which is sufficient to kill 
the yeast germs and check further fermentation. 

Of all the cooking processes now in use by civilised man, the 
baking of bread is, perhaps, the most important. The object of 
cooking flour in this manner is to make it light and porous, so that 
the digestive fluids may be easily incorporated with it. Flour eaten 
alone forms a glutinous or sticky mass which is quite indigestible 
and difficult to swallow, besides being comparatively tasteless. 
There are many variations in the process of bread-making, but all 
are based upon the same principle — the development of carbonic-acid 
gas throughout the mass of dough, which bubbles up and causes it 
to " rise " or forces it apart. In general, the process involves a loss 
of about 1 per cent of C0 2 and 1 per cent of alcohol. The loss of 
volatile products represents a loss of but 1.58 per cent of starch. 
Of the remaining starch less than 8 per cent is converted into soluble 
form (dextrin), but many of the starch granules are ruptured or dis- 
integrated. A very small percentage of fat also disappears in the 
process of baking. 

Development of Carbonic-acid Gas. — Carbonic-acid gas may be 
generated or introduced in four ways : I. Indirectly by natural fer- 



138 FOODS AND FOOD PREPARATIONS 

mentation excited by the addition of the yeast fungus, Torula or 
Saccharomycetes cerevisice. II. By the use of " leaven," a name given 
to old dough in which fermentation has already occurred. III. By 
the addition of baking powders. IV. Directly by " aeration." 

I and II. Bread made by Yeast or Leaven. — When bread is made by 
yeast or leaven the process, which may be divided into three stages, 
is as follows : 

(1) The wheat or other flour, finely ground, is mixed into a thick 
paste with water, which may be either warm or cold, and to which 
the ferment, together with a little salt, is added ; the mass is thick- 
ened with flour to form a dough, and the dough is well worked by 
hand or kneaded so that its several ingredients may become most 
thoroughly incorporated. If this is not done properly the bread is 
lumpy or of uneven porosity. The entire mass may be prepared at 
once, or a small part of the flour is first allowed to ferment for a 
short time, and then is kneaded into the remainder. 

(2) The dough is next set aside for some hours in a warm place 
to rise. This process consists of a fermentation which is produced 
in the flour by the action of the yeast, resulting in the freeing of 
carbon dioxide and water. The accumulating carbonic-acid gas en- 
deavours to escape in bubbles, which become entangled in the more 
or less tenacious gluten of the flour. Upon the size and number of 
these bubbles depends the porosity of the bread, and this in turn is 
modified somewhat by the kind of flour used, the quantity of the fer- 
ment, and the rapidity with which the development of carbonic acid 
is allowed to proceed. 

(3) The final stage consists in the baking of the dough after it 
has risen. The heat of the oven, by expanding the carbonic-acid 
gas, makes the bread still more porous and " sets " the walls of the 
little cavities which have formed so that the loaf maintains its shape. 
The gas is finally driven off, together with a large quantity, but not 
all, of the water. The baked bread is therefore considerably lighter 
in weight than the dough, much drier, and porous. 

The water added to make the dough escapes in part through 
evaporation, and the external portion of the bread becomes drier and 
browner than the interior or crumb, and constitutes the crust. The 
thickness of the crust will depend upon the character of the flour 
used, the temperature of the oven, and the duration of the process 
of baking. Bauer claims that the crust contains less nitrogenous 
material than the crumb, but this is contradicted by Dujardin-Beau- 
metz, and there is no definite reason why it should. 

With the exception of these changes, bread has practically the 
same composition as its original flour. 

Mixing meal or flour with fat tends to prevent the evaporation 
of water from the bread. 

The chief art in baking bread consists in arresting the yeast fer- 



VEGETABLE FOODS I 39 

mentation of the dough by the heat of the oven (300 to 400 F.) at 
exactly the right period. If fermentation has not proceeded far 
enough the bread is tough, or sodden, or lumpy, whereas if it has 
gone too far it acquires a sour taste by the development from the 
carbohydrates or organic acids, such as acetic, butyric, and lactic, 
which are both unpalatable and unwholesome. Fermentation pro- 
duced by the use of leaven instead of yeast is much more difficult to 
control, and these acids, therefore, are more likely to be formed. The 
bread made with fresh brewers' yeast is by many esteemed to have 
the best flavour. The process of bread-baking also causes the 
starch granules to burst, if this has not already occurred from ab- 
sorption of water in the dough, and results in the conversion of 
some of the starch into dextrin, with the further formation of alco- 
hol and sugar (glucose). About 6 to 8 per cent of the starch is thus 
made soluble. There are several minor chemical changes, and the 
entire action of yeast and heat upon the dough is thus summarised 
by H. Snyder and L. A. Voorhees (U. S. Department of Agricul- 
ture Bulletin No. 67, 1899) : 

" (1) The fermentation of the carbohydrates and the production 
of carbon dioxide and alcohol ; (2) the production of soluble carbo- 
hydrates, as dextrin, from insoluble forms, as starch ; (3) the pro- 
duction of lactic and other acids ; (4) the formation of other volatile 
carbon compounds ; (5) a change in the solubility of the proteid com- 
pounds ; (6) the formation of amid and ammonium compounds from 
soluble proteids ; and (7) the partial oxidation of the fat." 

About 2 per cent of the weight of the flour used is lost in volatil- 
ising various organic products. With prolonged fermentation this 
loss may amount to 8 per cent. 

The soluble dextrin has the physical properties of a gum. It 
is obtained by heating starch to 300 to 400 . In steam-cooked ce- 
reals also, the starch is partially dextrinised. 

III. Baking Powders. — Carbonic-acid gas may be developed in 
bread by the action of baking powders. These powders are very 
extensively employed, and " a conservative estimate of the quantity 
of baking powder used in the United States each year places the 
figure considerably above 50,000,000 pounds " (Clark). 

There has, however, been much argument in regard to their 
wholesomeness, and elaborate researches in chemistry and the physi- 
ology of digestion have been conducted to determine whether or 
not the continued use of these ingredients in bread is injurious. The 
so-called baking powders are manufactured by the combination of 
many different ingredients, such as sodium carbonate with tartaric 
acid, the acid phosphate of lime with sodium carbonate and potas- 
sium chloride (Liebig-Horsford), or a combination may be used of 
ammonium carbonate with hydrochloric acid. It is claimed by the 
advocates of the use of baking powders that they possess many ad- 



140 FOODS AND FOOD PREPARATIONS 

vantages, such as the fact that the bread rises quicker, and that al- 
though fermentation does not occur, the bread is more porous, and 
hence more digestible, and that its taste is not impaired. On the 
other hand, it is argued that such bread is practically less wholesome, 
and that its continued use, from the introduction of so many chem- 
icals, especially when ammonium carbonate is employed, proves irri- 
tating to the stomach and may excite dyspepsia and gastric catarrh. 
Even when not used for the making of bread these baking powders 
are often employed in the preparation of various forms of cake 
where lightness and quickness in making are important features. 

Baking powder when pure should consist only of cream of tartar 
(acid tartrate of potash, obtained as a precipitate in the casks in which 
wine is made) and soda, with a little flour added, and should be free 
from alum, ammonia, etc. Mixed with water and dough, the soda 
is split by the acid tartrate, liberating carbonic-acid gas. Alum is 
sometimes used in baking powders with soda. Its action is less reli- 
able, and in large quantities it is astringent and injurious to digestion. 

IV. Aerated Bread. — The process of aerating bread consists in 
the forcing of carbonic-acid gas into the dough under pressure. The 
gas is generated by the action of sulphuric acid upon lime, and while 
there are several methods of its use, in general, about one cubic foot 
of gas is applied to fourteen pounds of flour, although not over one 
half of this quantity remains in the dough. It is claimed for this 
process that the bread is exceptionally light, dry, and porous, that 
there is no danger of malfermentation, with production of acidity, 
and that it sooner hardens when exposed to the air as compared with 
home-made bread prepared with yeast. 

Aerated bread keeps fresh longer than other varieties. It has a 
peculiar taste which, however, is preferred by some people. It is 
claimed as a further advantage for its manufacture that the bread 
requires less kneading by the sometimes dirty hands of the baker. 
Some twenty or thirty varieties of germs are usually to be found 
beneath the finger nails of persons who are ordinarily cleanly. If 
special care is not taken by those who prepare bread it is possible 
for disease germs to be introduced from beneath the nails into the 
dough. It has been claimed that various infectious diseases might 
be transmitted in this manner. The danger, aside from any aesthetic 
consideration, is, however, grossly exaggerated, as the fermentative 
processes, together with the prolonged heat used in baking, are 
fatal to both germs and spores. In aerated bread salt is added as in 
the other processes, with the result of making the bread firmer and 
somewhat whiter. 

There are many cereals, such, for example, as oatmeal and the 
coarser whole meals, which are exceedingly wholesome when cooked 
by some methods, but which cannot be baked into good bread be- 
cause of the difficulty of making them porous, and their attempted 



VEGETABLE FOODS 141 

use in this form usually results in dyspepsia, with heartburn and 
acid fermentation. 

It is pointed out by Sir Henry Thompson that when coarse meal 
is necessarily used for bread-making, it, " being a bad conductor of 
heat, will have a hard, flinty crust if baked sufficiently to cook the 
interior ; or it will have a soft, dough-like interior if the baking is 
checked when the crust is properly done." For this reason he ad- 
vises baking the flour in the form of flat cakes, which can be uni- 
formly heated throughout. Palatable cakes can be made in this 
manner by a mixture of wheat meal and Scotch oatmeal. 

The addition of boiled rice flour in bread-making causes the bread 
to become more adhesive and to hold more water. Hence bakers 
sometimes resort to this means to make their bread heavier. By 
turning the fresh loaf over occasionally as it lies upon the shelf the 
water is prevented from gravitating to the bottom and making it 
sodden. While the primary object of bread manufacture is to ren- 
der the starch more soluble, the gluten is also easier digested after 
fermentation. Freshly baked bread is much less digestible than dry 
bread for the reason that, being more moist, it tends to form a tena- 
cious bolus in the mouth which is not readily mingled with the saliva 
or other digestive secretions. Dry bread, on the other hand, crum- 
bles into smaller particles, which are easily acted upon by the saliva 
and pancreatic juice. For the same reason, the crust of bread is 
more digestible than the interior part of the loaf. 

Spoiled Bread. — Bread may be unfit for use from being made of 
adulterated or too old flour, from turning sour from bad flour devel- 
oping excess of lactic acid, from becoming bitter from yeast, from 
becoming sodden from insufficient fermentation or aeration, and it 
may grow mouldy from exposure to air when it is too moist. 

" Most of the diseases of the War of 1812 were due to defective 
food, and in 90 per cent of the cases the flour was at fault. In the 
War of the Rebellion similar reports were often received " (Wood- 
ruff). 

VARIETIES OF BREADSTUFFS 

Bread of different kinds constitutes the staple starchy food for 
Americans, as the potato does for the Irish peasantry and macaroni 
for the Italians. 

The quantity of bread consumed varies somewhat with the ability 
to obtain other articles of diet. For example, persons residing in 
large cities are wont to eat a larger percentage of animal food and 
less breadstuff than those in the country. The French labourer con- 
sumes daily eight hundred grammes of bread in the country against 
five hundred in the city. The most important bread used, both from 
the standpoint of its nutritive value and the quantity consumed, is 
•derived solely from wheat flour ; but, for economical or other reasons, 



142 



FOODS AND FOOD PREPARATIONS 



this flour is sometimes advantageously mixed with potatoes or bean 
flour. The latter, added in the proportion of i part to 10 of wheat, 
gives a white bread rich in nitrogen and highly nutritious. Corn 
flour may be mixed in the same proportion. 

Composition of Breads and Crackers of Various Kinds (Clark) 



Water. Nutrients. Protein. 



Fats. 



Per cent. Per cent. Per cent. Per cent 



Wheat bread 32.51 

Graham bread (wheat; 34-2 

Rye bread 

Boston crackers 

Soda crackers 

Pilot crackers 

Graham crackers 

Oatmeal crackers 

Oyster crackers 



30.0 

8.2 
3.0 

7-9 
5-o 

4-9 

3.8 



67.5 
65.8 
70.0 

9i 
92 
92 
95 

95 
96 



8 


8 


1.9 


55- 


9 


5 


1.4 


53- 


8 


4 


0.5 


59- 


10 


7 


9.9 


68. 


10 


3 


9.4 


70. 


12 


4 


4 4 


74- 


9 


8 


13-5 


69. 


10 


4 


13-7 


69. 


11 


3 


4.8 


77- 



Carbo- 
hydrates. 



Per cent. 



Mineral 
waters. 



Per cent. 
I.O 
1.6 
1.4 
2. 
I, 
I . 
2. 
I, 
2. 



Wheaten Flour and Bread. — In the average composition of 
wheaten bread nitrogen exists in the proportion of 1 part to 21 of 
carbon (Yeo). Besides the deficiency in nitrogen, there is but a trace 
of fat in refined flour, a trace of acid, and little mineral matter. 

The following table from the U. S. Department of Agriculture 
Bulletin No. 67, 1899, gives the percentage of 

Proteids in Wheat Flour 

Albumin 0.3 per cent. 

Globulin 9 

Proteose body 2 

Gliadin 6.8 

Glutenin 4.5 



Total 12.7 

The best wheaten flour for wholesome bread should be of a slight 
yellowish-white tinge, and not too fine. The colour fades as the 
flour becomes dry. 

Yellow flour is sweeter and more nutritious than white pastry 
flour, although it makes a darker bread. The flour contains 10 to 11 
per cent of gluten. Such flour when mixed with water should form 
a dough which is both coherent and ductile. These properties are 
due to the gluten which it contains. 

Bread made from good flour should be porous, but not filled with 
large holes, and should have the proper consistence and firmness to 
cut well in thin slices. Wheaten flour contains much less crude 
gluten after thorough baking, for in the process of strongly heating 
flours containing nitrogenous material, the proteid as well as the 
starch becomes more soluble in water (Leeds). 

Heavv, sodden bread has been insufficiently fermented. 



VEGETABLE FOODS I43 

Tough, moist, imperfectly baked, or hot bread is liable to ex- 
cite further fermentation in the stomach, causing heartburn and other 
symptoms of dyspepsia. The digestibility of such bread is promoted 
by heating it to drive off the moisture, and by spreading it well with 
butter to prevent it from agglutinating in the stomach. 

Water continues to evaporate from hot fresh bread, and such 
bread should not be covered tightly, or else it becomes sodden. 

Stale bread and dry toast are both more digestible than fresh 
bread. In stale bread water is evaporated to a great extent, so that 
the bread becomes friable and is more readily masticated and mingled 
with digestive fluids. The fact that stale bread on being warmed 
over becomes softer is accounted for on the hypothesis that in dry- 
ing the water has not all been evaporated, but that some of it has 
combined with the flour, forming a new compound, which is disso- 
ciated by the further application of heat (Yeo). 

In toasting, the digestibility of bread is still further promoted by 
additional heat, and the superficial layers are browned and altered in 
flavour, acquiring a taste somewhat similar to caramel. Water is 
evaporated, and a slice, if sufficiently thin, bakes dry and crisp 
throughout, but if thick, the outer layers are scorched while the mass 
within may become even softer than before toasting. 

Buttered dry toast is a digestible form of invalid food, for if the 
butter be spread thin while the toast is quite hot it penetrates to the 
interior, and both fat droplets and starch crumbs mutually protect 
each other from cohering in large masses. The butter, moreover, 
enables one to eat more bread in this form. The same is true of 
milk toast, and this furnishes in addition a means of giving consid- 
erable milk to patients who are unwilling to drink it. 

Whole-meal Bread. — For some flours the whole of the wheat is 
used, the gluten nitrates and phosphates being all retained. They 
are more delicate than oatmeal, and more digestible. 

Wheat yields soluble matter, such as albumin and dextrin, 
amounting together to about 10 per cent, besides various salts. The 
insoluble matter of the grain is chiefly starch and gluten, which con- 
stitute from 72 to 75 per cent. Wheaten bread contains about 25 
per cent of carbon and 1.2 per cent of nitrogen (or about 8 per cent 
of protein material). The proportion which these elements bear to 
each other and which is needed for maintenance of life is carbon 
fifteen to nitrogen one ; hence it appears that wheaten bread alone 
is not an economical food. If man is to live upon it alone for any 
length of time, brown bread or Graham bread is better than the vari- 
eties made from fine flour, from which latter the nitrogenous ele- 
ments have been largely removed by milling. A " bread-and-water 
diet " is proverbially a reducing diet, and as such it is given to in- 
subordinate prisoners (see Diet in Prisons), but they cannot subsist 
upon it for longer than two or three weeks at most. 



144 FOODS AND FOOD PREPARATIONS 

Bread made of whole meal is usually not so light as that made 
with refined white flour. The explanation of this is said to be the 
fact that the silicious envelope of the grain contains a ferment resem- 
bling diastase, which is called cerealin. While the dough is rising, 
this ferment acts upon a good portion of the starch, forming viscid 
compounds of dextrin and sugar, which by agglutination prevent the 
carbonic-acid gas from purring up the bread as much as it should. 
On the other hand, too much attrition in the mill ruptures the indi- 
vidual starch granules, and without the use of artificial baking 
powders the bread will not be light and wholesome. " Seconds " is 
a medium ground flour which makes a digestible bread. 

The British Commissioners of Prisons recommended the use of 
whole-meal bread for convicts at hard labour on account of its greater 
cheapness and nutritive value, but advised a modification in the pro- 
cess of its manufacture. The dough is made of flour from which the 
sharps, etc., have been removed. The latter are then added and 
mixed thoroughly with the dough just before it is ready for baking, 
and it is claimed for this process that there is not time for the cerea- 
lin to act, and consequently the bread is much lighter. 

Pumpernickel is a German black bread made with unbolted meal 
and sour dough. It is somewhat laxative. 

Zwieback is a thoroughly dry form of bread, which is very whole- 
some for invalids. 

Graham bread — so called after Sylvester Graham, who advocated 
its use — differs from white wheat bread by containing the outer coat- 
ings of the wheat kernel, called bran, which contain a larger percent- 
age of albuminous material and of phosphate. The bran, however, 
while containing serviceable food products, is so difficult of digestion 
that it tends to irritate the mucous membrane of the intestine and 
increase peristaltic action. For this reason it is more laxative than 
white wheat bread, but also less nutritious. 

It is a popular idea that coarse bread, black bread, whole-meal 
bread, etc., are more nutritious than the bread made from refined 
white wheaten flour or delicate French breads. This is not neces- 
sarily true, and much depends upon the digestive organs of the in- 
dividual. In a report on the digestibility and nutritive value of 
bread (Bulletin No. 85, U. S. Department of Agriculture, 1900) by 
Charles D. Woods and L. H. Merrill, they show the coefficient of 
digestibility of white bread averages 93.37 per cent (in some samples 
it is as high as 97.06 per cent), whereas that of whole-wheat bread is 
91.50 per cent, and that of Graham bread is but 86.94 per cent. They 
also found that bread was rendered more digestible when eaten with 
milk than if eaten alone, the increase in digestibility amounting to 
15 per cent. There are peasants in Europe who can thrive upon the 
coarsest forms of sour, black bread, and there are others who can 
use different forms of fermenting foods and beverages which to those 



VEGETABLE FOODS I45 

unaccustomed to them would prove most injurious. Thus gener- 
alisations cannot be made, for much depends upon the condition of 
life of the individual and the general habit of his digestive organs. 
Wheat bran contains about 15 per cent of nitrogenous material, 3.5 
per cent of fatty matter, and 6 to 7 per cent of mineral substance, main- 
ly phosphates (Yeo), all of which materials, from a purely theoretical 
standpoint, should be nutritious, but, practically, little bran is ab- 
sorbed, and it is often irritating, especially where feebleness of the di- 
gestive organs exist. As proved by the researches of Professor Sny- 
der, this is the reason why bread made from patent flours is so much 
more digestible than that made from Graham or whole wheat flour. 

According to Bauer, " with wheaten bread, rice, macaroni, etc., 
the carbohydrates are utilised to within 0.8 or 1.6 per cent, whereas 
of black bread, potatoes, and the like, 8 to 18 per cent of the carbo- 
hydrates are passed with the feces." 

Decorticated flour is prepared by special methods of grinding with 
the object of removing two or three of the outermost and toughest 
coverings of the grain, but not the inner envelope. Yeo says of 
bread made from such flour, that while it may be suitable " for 
young and growing persons with sound and active digestion," it may 
" prove very indigestible to adults leading sedentary lives. It makes 
a bread which is usually heavier, moister, and of closer texture than 
that made from the finest wheat flour." 

When digestion is not vigorous, it is better to obtain the neces- 
sary nitrogenous material from animal sources. The special uses of 
coarse forms of bread will be pointed out under the treatment of 
constipation. 

The portion of grain which is useless in the diet of man is whole- 
some for some of the lower animals, who can convert it into flesh, to 
be eventually eaten by man. 

Gluten Bread. — Bread made from gluten flour is useful where 
there is a tendency to obesity, and is given to diabetics. It may be 
toasted like ordinary bread. The best bread of this kind is made in 
Paris, and contains from 40 to 50 per cent of gluten. Another good 
gluten biscuit is made by the Battle Creek (Mich.) Sanitarium Health 
Food Company, but there are many so-called gluten breads in mar- 
ket which do not contain above 16 per cent of gluten, the remainder 
being starch. 

Poluboskos is a gluten food which is said by those interested in its 
manufacture to contain only 0.4 per cent of starch. The name indi- 
cates " much nourishment." It is given to diabetics in doses of one 
or two teaspoonfuls in milk. 

Rye Bread. — Next to wheat, rye is the most important bread- 
making flour, although it is less digestible for invalids, and it may be 
mixed with wheat flour in the proportion of two parts of the former 
to one of the latter. 



146 FOODS AND FOOD PREPARATIONS 

It has the advantage of keeping fresh longer than pure wheaten 
bread, and if well made it is wholesome and somewhat more laxative, 
but contains much less gluten than white bread from wheat. It 
should be baked in a hotter oven to insure its digestibility. 

Biscuits, Pastry, Puddings, etc. — In addition to bread an almost 
innumerable variety of biscuits, cakes, pastry, tarts, pies, etc., are 
prepared by the addition, in various proportions, of flour, milk, 
cream, butter, or other fat, sugar, eggs, flavouring extracts, and 
fruit, such as raisins. 

For making pastry, cake, and puddings of different kinds, the 
finer grades of wheat flour are usually employed, although corn and 
Indian meal are sometimes used. 

The dough is raised in such preparations by the help of yeast, 
alcohol, fat, baking powders, or whipped white of egg. A hot fire 
is used in the cooking, and the puddings are either baked, boiled, or 
steamed, so that the flour is altered by the heat in much the same 
manner as in the manufacture of bread. 

These foods vary so much in richness and digestibility that it is 
difficult to formulate any definite rules for their use. In general, 
they must be avoided by all persons having indigestion, dyspepsia, 
or, in fact, any severe illness ; but farinaceous puddings, simply made 
and thoroughly cooked, with the addition of eggs and milk, play an 
important part in hospital dietaries, and are very good foods for 
convalescents. 

Boiled or steamed puddings, being unfermented and surrounded 
with abundant water, are very likely to be sodden or stringy, and 
therefore wholly indigestible. 

Pastry, even when light, is apt to be too rich, and if not well 
cooked it is sodden or tough and almost certain to disagree, mainly 
because of the changes which the high grade of heat produces in the 
butter or other fats used in its preparation. 

PREPARED FARINACEOUS FOODS 
{Often called " Infant Foods'" or " Prepared Baby Foods'') 

Prepared farinaceous foods are made by the following methods : 
1. Application of heat alone. 2. Digestion with malt or diastase 
combined with heat. 3. After dextrinisation, the food is evaporated 
with milk or cream. 

The prepared farinaceous foods may be eaten alone or diluted 
with water, but they are usually given to invalids in a cup of broth 
or beef tea, which disguises their sweetness. The sweeter varieties 
are best combined with milk. 

1. Farinaceous Foods prepared by Heat alone. — Flour ball, Ridge's 
Food, Blair's Wheat Food, Schumacher's Food, Imperial Granum,. 
and Robinson's Patent Barley are examples of this class. 



VEGETABLE FOODS I47 

Wheat and oats are sometimes prepared by roasting (not steam- 
ing), a process which removes all moisture besides producing some 
chemical changes in the fats and starches. Cereals treated in this 
manner will keep from moulding in any climate, and are both diges- 
tible and nutritious. 

Imperial Granum is a type of a large class of prepared foods, 
the basis of which is starch, modified, it is claimed, so as to render 
it easily digestible. Such foods are often fed to newborn infants 
to the exclusion of milk, but no greater mistake can be made, for their 
digestive apparatus is wholly unfit to deal with starch in any form. 
The human infant is designed to be nursed at the breast for the 
first year of life, and Nature has furnished ample food for it which 
is wholly devoid of starch. The saliva and pancreatic secretion 
upon which the digestion of starches depends are not fitted for this 
work at all during the first eight or nine months of life, and then 
only partially, hence starchy foods, " farinaceous baby foods," should 
never be given at all before that age as foods, and should only be 
used very sparingly, if at all, as mechanical diluents of milk. More- 
over, in such simple starchy foods as arrowroot the proportion of 
tissue-building to heat-producing foods is one to twenty, whereas in 
human milk it is one to five (Starr). Even when the starch of in- 
fant foods is rendered soluble or dextrinised or converted into sugar, 
the absorption of too much of such material diverts energy which 
can be better employed in controlling metabolism in other ways or 
removing waste. 

Granum is composed of over three fourths starch, made into a 
fine flour. One teaspoonful of it should go to each three ounces of 
water, in which it is boiled for ten minutes. An equal quantity of 
milk is then to be added, and the mixture must be again boiled for 
five minutes. 

The mixture may sometimes be fed to infants after the eighth or 
ninth month, but only once or twice in twenty-four hours. It is a 
useful temporary food for adults with irritable stomachs. 

Flour ball is prepared by boiling wheat flour tied in a bag, with 
the supposed purpose of converting it into dextrin, and it is a popular 
belief that this conversion is quite complete ; but it requires a tem- 
perature of 250 F. to dextrinise starch, and this degree cannot be at- 
tained by the process. Leeds has shown by recent analyses that even 
after seventy-five hours of continuous boiling the percentage of solu- 
ble carbohydrates is increased by only 0.05 of 1 per cent, whereas 
some of the prepared foods contain from two to six times as much 
soluble carbohydrate as wheat flour. Flour ball tastes flat and in- 
sipid, owing to the long boiling dissolving out fat, soluble albumi- 
noids, and salts (Leeds). 

Starr gives the following rule for the making of flour 
ball: 



I48 FOODS AND FOOD PREPARATIONS 

Tie one pound of unbolted wheat flour firmly in a pudding bag 
and boil for ten hours. At the end of this time it will be found, on 
opening the bag, that the outer layer of the ball is doughy, while the 
interior is hard and dry, it having been baked by the long-continued 
heat. This hard mass may be used for infant feeding in the latter 
part of the first year, but it should not be given more than twice a 
day. The flour ball is grated fine, and it may then be prepared, 
according to Starr's rule, as follows : " Rub one teaspoonful of the 
powder with a tablespoonful of milk into a smooth paste, then add a 
second tablespoonful of milk, constantly rubbing until a cream-like 
mixture is obtained. Pour this into eight ounces of hot milk, stirring 
well, and it is then ready for use. The flour ball thus prepared is 
quite digestible, and it prevents the formation of large curds of 
milk. 

As a diluent of milk it is much cheaper for the poor than the pre- 
pared amylaceous foods which are on sale. 

2. Farinaceous foods digested with malt or diastase with heat are 
often called " Liebig's Foods." 

Liebig's foods are made of equal quantities of wheat flour and 
barley malt, with bran, and 1 per cent of bicarbonate of potassium. 
These ingredients are mixed into a paste with water and digested 
for several hours at fixed temperatures, until the starch is trans- 
formed into soluble carbohydrates, maltose, and dextrin. The food 
is strained, pressed, and extracted with warm water, evaporated, 
dried, and pulverised, when it is ready for use. 

Examples of Liebig's type of dextrinised foods are : Mellin's 
Food, Horlick's Food, Savory & Moore's Infant Food. 

According to Leeds's analysis, the best samples of Mellin's* and 
Horlick's foods contain no starch, but a large percentage (Mellin's 
68.18 per cent, Horlick's 76.83) of soluble carbohydrates, and about 
10 per cent each of albuminoids — if the process is complete. Savory 
& Moore's food he finds contains considerable starch. 

Mellin's Food consists of brown sweetish granules, easily soluble 
in both hot and cold water, milk, etc. It is made of coarsely ground 
wheaten flour with the addition of malt and potash. It is then 
digested with water at a moderate temperature to form dextrin and 
sugar. Afterwards it is strained through sieves and evaporated in a 
vacuum pan. 

Mellin's Food is often fed to infants, but it contains too much 
sugar without fat for a wholesome baby's food for continued use in 
quantity. It may be resorted to temporarily when good cow's milk 
cannot be obtained. The food may be prepared for use as follows : 

For an Infant One Month Old 

Mellin's Food 5 level teaspoonfuls. 

Fresh milk 10 tablespoonfuls. 

Hot water 22 



VEGETABLE FOODS I 49 

For an Infant of Three Months and for Delicate Children 

Mellin's Food 8 level teaspoonfuls (equal to 1 heaping tablespoonful). 

Fresh milk 16 tablespoonfuls (equal to \ pint). 

Hot water 16 tablespoonfuls (equal to \ pint). 

For Infants of Six Months and Over 

Mellin's Food 2 heaping tablespoonfuls. 

Fresh milk 24 tablespoonfuls (equal to £ pint). 

Hot water 8 tablespoonfuls (equal to \ pint). 

Mix the Mellin's Food with a little hot water into a smooth paste, add the 
remainder of the water and the milk, and mix thoroughly. Keep this mixture on the 
ice or in a cool place. 

Bengers Food is a preparation of wheateil flour to which, after 
cooking, pancreatic extract is added. When mixed with warm milk 
both milk and flour are newly digested. A tablespoonful of the food 
is dissolved in two ounces of cold milk. Then half a pint of boiling 
milk or milk and water is slowly stirred in. Further pancreatinisa- 
tion is then arrested by boiling for twenty to thirty minutes. The 
preparation has no bad taste and is a nutritious and digestible food 
in cases of gastric ulcer, phthisis, dyspepsia, etc. 

3. Foods which are Dextrinised and then Evaporated with Milk or 
Cream. — These are sometimes called " milk foods." Such are Lac- 
tated Food, Malted Milk, Loeflund's Cream Emulsion, Nestle's 
Food, Gerber's Food. 

The general process by which foods of this class are made is as 
follows : 

Wheaten or other flour is first made into dough, baked, ground, 
mixed with more or less condensed milk or cream, and then dried at 
a moderate temperature. By addition of malt or diastase the starch 
is partially converted into dextrin and maltose, and the albuminoids 
are rendered slightly more soluble, the casein is dried, and the lact- 
albumin is precipitated. 

One form of " cereal milk " is made from a mixture of wheat and 
barley meal with milk. 

It is claimed for some of the malted foods prepared for infant 
and invalid use that the artificial digestion is not wholly completed, 
and this is said to be an advantage in stimulating the digestive organs. 

Malted milk is a powdered sterilised preparation of pure cow's 
milk and extracts of malted barley and wheat, the starch of which 
has been converted into dextrin. The mixture is dried in vacuo. 

The casein of the milk is predigested by a vegetable ferment. 
The preparation keeps well while hermetically sealed, and when re- 
quired for use for an infant, from one to four teaspoonfuls are dis- 
solved in from eight tablespoonfuls to a half pint of water. For 
adults, two tablespoonfuls of the powder in a half pint of water make 
the strength of cow's milk. The idea of this preparation is to furnish 



150 FOODS AND FOOD PREPARATIONS 

a substitute for human milk which will keep well, be always ready 
for use, and in which dextrin takes the place of additional fat. 

It resembles Mellin's Food, except that it contains some, though 
not enough fat. It is used in about the same proportion. It makes 
a better invalid food for adults than for infants, and patients with 
enteric fever and severe gastro-intestinal disorder take it with benefit. 

Nestle' 's Food is prepared in Switzerland, at Vevay, from sterilised 
fresh cow's milk to which wheaten bread crust is added after dex- 
trinisation by additional heat. Cane sugar is mixed in, and the mass 
is dried, pulverised, and hermetically sealed in tins. For use it re- 
quires dilution with water. 

Carnrick's Food is composed of evaporated or desiccated milk 
partly peptonised and thoroughly sterilised by heat, 45 parts ; dextrin 
and soluble starch, 45 parts ; milk sugar, 10 parts. 

Eskay's albuminised food consists of the prepared cereals — oats, 
barley, maize, and wheat together with lactose and Qgg albumin. It 
contains 11.33 P er cent °f tota ^ solids. 

Bread Jelly. — A bread jelly may be made to add to milk for 
invalids and for use while weaning infants who are old enough to 
digest a little starch — i. e., over one year of age. The crumb of 
stale bread is broken into small fragments and covered with boiling 
water, in which it is allowed to soak until well macerated. The 
water is then strained off, fresh water is added, and the mass is boiled 
until quite soft. On cooling, a jelly forms which may be mixed with 
milk in any desired proportion. 

Farina is a general name meaning flour, and is defined by Web- 
ster as " the flour of any species of corn or starchy root " ; but in 
England the term corn is used as a general name for any grain grow- 
ing in ears. Farina as sold by grocers in this country is often made 
from wheat, but much of the gluten and bran has been separated, 
rendering it less nutritious than whole wheat. In cases of diarrhoea 
it is more bland and less irritating than whole wheat. The name 
farina is also applied to fine white potato starch, which forms a jelly 
when cooked, like arrowroot. 

Wheatena is a nutritious food containing all the wheat berry ex- 
cepting the husk, and thereby differing from finer preparations in 
which the layer of gluten cells is removed with the bran. The starch 
granules, moreover, have been ruptured by heat. It is commonly 
eaten as a thin mush or porridge. 

Cracked or rolled wheat has similar advantages. 

Shredded wheat and pulled bread are modified breadstuff's which 
have lately become deservedly popular for dyspeptics on account of 
their easy digestibility. 

Shredded wheat biscuit is made of wheat which is thoroughly 
cleaned, washed, cooked, and treated by machinery which draws out 
the wheat kernels into long, continuous filaments, thus breaking 



VEGETABLE FOODS 151 

•down their structure without separation of the component parts. 
Eighty such filaments are obtained within a space four inches wide ; 
they are porous and, unlike dough, are capable of absorbing the 
digestive fluids, thus no leavening or baking powder is required. 
The shreds are folded by mashing into oblong biscuits, which are 
recooked at successive temperatures until all moisture is driven off 
and they are ready for use. They may be eaten soaked in milk, 
cream, or broth, or moistened with hot water and buttered. 

Crackers. — All kinds of crackers enter more into the dietary in 
America and England (where they are called " biscuits ") than in 
any other country. The lighter forms of sugar wafers are nutritious 
and very easily digested by invalids having mild gastric disorder, 
for the starch has been well torrefied. 

Crackers vary much in hardness and flavour, but, generally speak- 
ing, they are quite as digestible as good bread. The simplest forms, 
such as water crackers or milk crackers, are made with flour and 
water or milk, to which a little salt is added, after which they are 
baked in flat shapes so as to become hard and more or less brittle. 
Soda is sometimes added. If it is desirable to have them less friable, 
butter may be added in small quantity. The hard unleavened prepa- 
rations known as " ship biscuits," " hard-tack," and " pilot biscuits," 
which form an important article of diet for sailors at sea, are manu- 
factured upon these principles. 

Ship biscuits are so dry and firm that they are much less bulky 
than bread, and it is estimated that three fourths of a pound of such 
biscuits is equivalent to one pound of bread in actual nutritive value. 

Most biscuits, if kept long exposed to the air, become exceed- 
ingly dry and tasteless, although they do not readily mould. Owing 
to their hardness and unpalatableness when long kept, it is found in- 
expedient to give them to soldiers or sailors to the exclusion of fresh 
bread whenever the latter can be obtained. The biscuits known as 
" hard-tack " are usually made five inches square and are perforated 
with small holes. They have the advantage of keeping well for a 
very long time and remaining edible, although they are not very 
palatable even when fresh. They are extremely tough, and require 
soaking in milk or water before they can be eaten. 

Granose is a flaky form of entire wheat biscuit prepared by the 
Battle Creek (Mich.) Sanitarium Health Food Company. It may be 
eaten with cream or hot milk, and is palatable and nutritious. Gran- 
ola is a similar preparation. 

Semolino is a name having two applications. In France it de- 
notes the hard central substance of the wheat grains which are 
retained in the bolting machine after separation of the finer por- 
tion which has passed through ; but in Italy the word is used to 
■denote the finer portion itself, consisting of fine hard granules 
rounded by grinding. The larger sizes contain much gluten, and 



152 FOODS AND FOOD PREPARATIONS 

may be used to thicken soups. The granules swell in water. When 
the grinding and sifting process is carried still further the starch 
granules are obtained in the fine powder which constitutes flour. 

Semolino is used extensively in the manufacture of what are 
called " alimentary pastes," such as macaroni. 

Macaroni is made by mixing semolino made from hard flinty 
wheat into a paste which is kneaded and put into a cylinder, the 
bottom of which is pierced with holes. A piston descends in the 
cylinder, and the paste issues from the perforations in the form of 
long thin tubes, which are cooled by a current of air, cut in lengths, 
and dried on screens. As much as twenty million pounds of maca- 
roni are manufactured annually in Lyons alone. It contains 16 to 18 
per cent of gluten, whereas bread holds 10 to 11 per cent. 

Sir Henry Thompson says, in speaking of macaroni, that, 
" weight for weight, it may be regarded as not less valuable for 
flesh-making purposes in the animal economy than beef or mutton. 
Most people can digest it more easily and rapidly than meat ; it 
offers, therefore, an admirable substitute for meat, particularly for 
lunch or midday meals." 

After thorough soaking and when well cooked by boiling or 
stewing in milk or stock it is very nutritious, and it is often agree- 
ably combined with cheese, although this is not advised for persons 
with feeble digestive power. Cooked alone with boiling water, 
macaroni is by many regarded as tasteless ; and as the art of cooking 
it properly is less understood in this country than in Italy, it is not so 
favourite an article of diet as it might be. 

The use of Italian pastes, such as spaghetti and vermicelli, in this 
country is extensive, but by no means as much so as their intrinsic 
value deserves. They are manufactured from flour from which the 
starch has been in part removed, and hence contain a relatively 
large proportion of nitrogenous matter. Although very whole- 
some they are tough, and require prolonged cooking. The vermi- 
celli which is sold in the form of letters, to use in soups, cannot be 
boiled sufficiently to be thoroughly digestible unless the letters lose 
their shape. 

Buckwheat. — Buckwheat, or blackwheat as it is sometimes called, 
is indigenous to temperate climates, and in some parts of the world, 
notably in Russia, Siberia, and Brittany, it constitutes a staple of diet, 
but in the United States it is the least imporant of the cereals, and 
is used rather as a luxury for making griddle cakes. The buckwheat 
produced in the United States is mainly raised in New York, Penn- 
sylvania, and some of the New England States. Buckwheat bread 
is nutritious, but it crumbles and does not keep well. 

Soya bread is made from an oily pea which grows in China and 
Japan, and is used sometimes by diabetics, for it contains over one 
third part of gluten and but 1.17 per cent of glucose. 



VEGETABLE EOODS I 53 

Millet and sorghum are grown in the warmest parts of Asia and 
Africa, and to some extent in southern Europe. In Russia millet is 
sold as a white meal. White sorghum, which is a grass or cane, is 
converted into flour called doura, and in Africa, mingled with barley, 
it is distilled into beer. A fine quality of alcohol may be made from 
it. In the United States it is mainly grown for molasses and sirup ; 
sugar is also made from it. Bread made from either millet or sor- 
ghum meal is fairly palatable and nutritious when warm, but when 
it becomes cold it grows dark and crumbles. The grains are hulled 
like barley and are ground into flour, which is either eaten pure or 
mixed with bread. Millet is a grass raised largely in India, China, 
Egypt, along the west coast of Africa, in Italy, Spain, and Portugal. 
There are many sub-varieties. It contains, on an average, over 7 
per cent of fat, nearly 10 per cent each of proteid and dextrin, 60 
per cent of starch, and 2 of sugar (Parkes). 

Eye. — Rye may be said to stand very close to wheat in impor- 
tance as a food. In Europe it is more in use for bread-making than 
in this country, where it is mainly eaten by the Germans. In Ger- 
many the rye production is double that of wheat, and in Russia it 
is three times greater. Former generations lived almost entirely 
upon rye in France, as they did upon oats in Scotland and parts of 
England, wheat being an almost unobtainable luxury. 

Rye yields a coarser, darker bread than w r heat, but is about 
equally nutritious, although not always so digestible, and it is some- 
what laxative. In general, the statements made in the preceding 
pages (pp. 1 37-141) in regard to bread-making, etc., with wheaten 
flour, may be applied to rye flour. 

Rye bread contains less gluten than wheaten bread, and it takes 
less time to raise and bake it, provided the oven is very hot. If prop- 
erly made it is easily assimilated, and many like its taste. 

Rye is often combined with wheat in France, under the name 
of meteil, and in Spain and Greece a mixture of the same name is 
made with barley instead of wheat. 

Corn. — Maize, or Indian corn, is very extensively grown in tem- 
perate and warm climates all over the world. It may be dried, 
parched, and roasted whole, or ground into meal of various degrees 
of fineness. 

There are some 300 varieties of corn, but the common kinds 
are known simply as white, yellow, and red. 

The chief preparations of corn are hominy, samp, cornmeal, 
cracked corn, cerealine, and maizena (a South American cornmeal, 
used in the manufacture of a drink called 4l chicca "). 

Aside from its use as a food, corn furnishes alcohol and liquor, 
as well as glucose and laundry starch. 

Chittenden and Osborn have made an elaborate research into the 
chemical composition of the " proteids of the corn or maize kernel " 



154 FOODS AND FOOD PREPARATIONS 

(American Chemical Journal, vol. xiii, Nos. 7 and 8, and vol. xiv, 
No. 1). These consist of " three globulins, one or more albumins, 
and an alcohol-soluble proteid " called maize fibrin or zein. 

Corn is a wholesome cereal, for it contains considerable fat and 
proteid as well as starch, and it furnishes abundant energy, produc- 
ing heat. It is very fattening for both the lower animals and man. 
In the Southern States and in France it is largely fed to horses. 

As a vegetable, corn is less used in Europe than in America, 
perhaps on account of the prevalent idea that it is a hog's food, 
although cornmeal is employed for baking into cakes and to mix 
with flour in bread-making. Eaten as a vegetable, unless very young 
and tender, corn is one of the least digestible foods, and canned corn 
is notoriously so. This is chiefly on account of the toughness of the 
husk of the kernel, which often is found in the feces practically 
unaltered by its transit through the body. Hence it may cause 
flatulency, indigestion, and diarrhoea. 

Cornmeal, on the other hand, is quite digestible, and, like oat- 
meal, is somewhat laxative. As compared with wheaten flour, it 
contains more fat, having about 9 per cent, but it is deficient in salts. 
It makes a dry, friable bread. 

Samp is a very digestible form of corn when well boiled. 

When maize becomes mouldy it causes the disease known as 
pellagra. (See Diet in Pellagra.) 

Polenta is a maize meal extensively used in Italy. 

Cornstarch is very white and soft. It contains 53 per cent of 
starch. The best grades are used as a substitute for arrowroot, and 
make a wholesome invalid food, being very white and soft. 

Indian meal is yellow, granular, and coarser than cornstarch. 

Mush is made of well-ground cornmeal or Indian meal. The 
cereal is boiled in salted water, and when cooked is not pasty, but 
mixes well with cream, and is very digestible and nutritious. 

Rice. — Although less eaten in this country than wheat, corn, and 
rye, except in the Southern States, rice constitutes the staple food 
of a majority of the world's inhabitants. Asia produces most of the 
rice consumed, but a little is grown in Spain, Italy, and Portugal. 
According to Clark, " in Asia a large part of the population con- 
sume 275 pounds per head a year," and nearly two billion pounds 
are used per year in Europe. In the United States, where rice 
was first introduced in 1694, it is chiefly grown in South Carolina. 
There are several hundred varieties of rice, the two principal classes 
being the dry or mountain rice, and the wet rice, which grows in 
flat marshland, periodically inundated. Both the Chinese and Japa- 
nese make a wine from rice, and a vinegar can also be obtained. 

The native Oriental method of treating rice is to beat the ker- 
nels of grain out of their husks in wooden mortars, and for European 
markets they are glazed by shaking in a sheepskin-lined drum 



PLATK V 



wjmaSB^ir*j-s 






"£ A A&* •■■•* 









Rice Starch x 150 












**M « 






& m t*+ 






Rice Starch x 450 
From Bulletin No. 13, Division of Chemistry, United States Agricultural Bureau 



BY 1 1,11 -Till; it UM'IIARltSiiN. 



VEGETABLE FOODS I 55 

(Clark). They are also bleached, and may be broken after decorti- 
cation and ground into a flour. 

Rice contains more starch than any other cereal — from 75 to 85 
per cent — and is an exceedingly digestible form of starch for in- 
valids when properly cooked, so that the individual grains are 
swollen or softened. This object is best attained by the process 
of steaming. The digestibility of plain boiled rice is improved by 
eating it with a little fresh butter, which coats the kernels and pre- 
vents their agglutination into a pasty mass. If the rice tastes in- 
sipid it may be spiced or flavoured with raisins. Rice pudding, 
milk and rice, and rice with beefsteak juice constitute excellent foods 
for young, growing children, and for use in convalescence from 
typhoid fever, diarrhoeas, and many other diseases. It is also advan- 
tageous to eat rice with fruit, such as apples or prunes. 

Rice should not be depended upon without some form of animal 
food, for it contains too little nitrogen to satisfy the needs of the 
system. 

Bread cannot be made economically from rice, on account of the 
small amount of nitrogen which this cereal contains, and the con- 
sequent lack of stability in the shape of the loaf, and unless wheat 
be added in large proportions, such bread is indigestible and watery. 

Barley. — Barley ranks very close to wheat in nutritive power, and 
cooked barley meal, like wheaten flour, contains gum, albuminoids, 
starch, and dextrin. As compared with wheat, barley contains more 
fat, salts, and indigestible cellulose, less protein, and less digestible 
carbohydrate. 

The employment of barley bread for food is of very ancient 
date, reaching back to the early days of the Greeks and Hebrews, 
but with the spread of the use of potatoes and the cheapening of 
w r heaten flour, it has fallen into comparative disuse, and in the 
United States barley is mainly used to thicken soups and in the 
manufacture of beer. In some of the Pacific States it is fed to 
horses. Pearl barley is made by depriving barley corns of their 
outer shells or covering, and then subjecting them to rubbing be- 
tween a single millstone and a sheet of rasped iron or wire cloth, a 
process which polishes the kernels and rounds them off. 

Barley water makes an excellent diluent of milk and a demulcent 
drink for infants and invalids. For the latter it may be flavoured 
with lemon juice. It may be made as follows : Grind half an ounce 
of pearl barley in a coffee mill, add six ounces of water, boil twenty 
minutes, add salt, and strain. It should be made fresh daily and 
kept in a cool place. It is better than oatmeal water whenever the 
bowels are loose. The latter, made in a similar manner, is to be 
preferred when constipation exists. 

Oatmeal. — Oats contain considerable fat, protein, salts, and indi- 
gestible cellulose, in addition to a large percentage of starch. They 



156 FOODS AND FOOD PREPARATIONS 

have been eaten in Germany for over a thousand years, and consti- 
tuted the original grain food for all Europe. 

Oatmeal is much less used than other cereals for bread because 
it lacks gluten, although it is still so employed to a limited extent 
among the poorer classes in France. It makes a dark, bitter bread, 
but forms a better porridge than can be obtained from rice or 
barley. The use of oatmeal porridge by all classes is very exten- 
sive throughout the United States. This is largely attributable to 
the improved methods of its preparation by high milling, rolling, 
etc. Scotch groats are prepared by removing the outer husk, leav- 
ing the grain almost whole. The grain is then reground between 
closer set millstones. It forms two grades of meal, the coarser of 
which is used for porridge and the finer to make bannocks or oat- 
meal cakes. A good deal of the oatmeal sold in America is identical 
with Scotch groats. True Scotch groats are heated by the miller 
over perforated iron plates and slightly parched for three or four 
hours before being ground. For those who can digest oatmeal well, 
it ranks among the cheapest and most satisfying of foods. 

The nutritious value of oatmeal is great, but it depends very 
largely upon the skill with which it is cooked. It is not infre- 
quently cooked in such a manner that the individual grains are left 
whole, but in this form the flavour is less well developed than it is 
by prolonged cooking ; the oatmeal granules are much more diffi- 
cult of digestion, and are capable of exciting gastro-intestinal irri- 
tation in feeble persons. But for many people oatmeal thus cooked 
possesses a decided advantage from the fact that it is less completely 
absorbed, leaving a considerable residue which adds to the bulk 
of fecal matter, excites peristaltic action, and reduces the liability 
to constipation. For most persons, however, and especially for all 
those with limited digestive power, oatmeal should be so thor- 
oughly cooked as to acquire the consistence which enables it to 
be easily poured, and on cooling it should form a tender, gelat- 
inous mass. 

Oatmeal is a very hearty food, and those who eat much of it 
should live a vigorous outdoor life. If ill-cooked and if given to 
very young children, it occasions colic, flatulence, and rashes. 

It is best when of recent crop and freshly ground. If it is kept 
long it absorbs moisture, and, losing its delicate flavour, becomes 
mouldy and sour. 

The following analysis of oatmeal is given by Letheby : 

Nitrogenous matter 12.6 per cent. 

Carbohydrates, starch, etc 63.8 " 

Fatty matter 5.6 " 

Mineral matter 3.0 " 

Water 15.0 

Total 100. o 



VEGETABLE FOODS I 57 

Oatmeal, like cornmeal, has more protein and fat than the flours 
and meals derived from other cerealia, and hence, like bread, it may 
be eaten daily without impairing the appetite. 

Revalenta, or revalenta Arabica, is a farinaceous food much eaten 
in some parts of Europe, which is a mixture of several meals, princi- 
pally ground peas, beans, corn, and lentils, but barley and oatmeal 
may be included. 

Arrowroot. — Arrowroot is derived from the rhizomata or root 
stocks of several kinds of tropical plants grown in both the East and 
West Indies. The roots are washed, reduced to a pulp, strained, 
dried, and pulverised into a very fine starchy flour. The best flour 
is made from the Maranta aruridinacea. It is obtainable in market in 
the form of a fine white powder, and consists of exceptionally pure 
starch, the granules of which are small and friable. It has a very 
bland, insipid taste, and it is as digestible or more so when cooked 
than any other starch which is used in making gruel or jellies for 
invalids. In the form of a jelly it keeps longer without souring than 
do many other forms of starchy food, such as the potato ; and in bad 
cases of dyspepsia, when much gastric irritation exists, it often con- 
stitutes a serviceable article of diet. Arrowroot is sometimes fed to 
young infants, but it is unwholesome for them, and ferments in the 
stomach. 

Tous-les-mois. — Tous-les-mois is a starch derived from a West 
Indian tuber by maceration, straining, washing, and drying. It is 
used for the same purpose as arrowroot. Its granules are the larg- 
est of any of the food starches, but they are quite digestible and 
nutritious for invalids. 

Salep. — Salep is a starchy food which is obtained from the tuber- 
cles of certain Oriental orchids. It is a mixture of starch and mu- 
cilage which makes a useful demulcent drink. 

Tapioca, Cassava. — Tapioca and cassava are made from the 
rhizomata of the Manioc utilissima or Manihot, a common plant in 
temperate and tropical regions. It is extensively grown in South 
and Central America, Africa, and the West Indies. Manioc flour 
forms the basis of food of the natives, and when made into bread 
and cakes it replaces the wheaten bread of Europe and North Amer- 
ica. Cassava contains a poisonous juice that must be first drained off. 

Tapioca, which is purified cassava, is made, like sago, by drying 
on hot plates, the clarified starch being first heated into a paste in 
large metal pans. It is an almost pure starch. The granules are 
not tough, and are very easily digested, so that they form one of 
the most useful of the amylaceous foods for persons with feeble 
digestion. Tapioca may be eaten alone in the form of puddings 
with cream or flavoured with lemon juice, wine, nutmeg, or other 
spice or aromatic, or may be used to thicken broths or soups. 
" Pearl tapioca " is a spurious article made from potato starch. 



158 FOODS AND FOOD PREPARATIONS 

Air-dry tapioca contains 11.97 per cent of water. Water-free 
tapioca consists of: protein 0.79, carbohydrates 98.90, and ash 0.31 
(C. D. Woods and L. H. Merrill). 

Sago. — Sago is an easily digestible form of starch derived from 
the pith found in the stem of different varieties of palm from 
Sumatra, Java, and Borneo. It is commonly sold in market in a 
granular form, and is known as " pearl sago." This is prepared by 
adding water to sago flour so as to form a paste which is run through 
sieves to granulate it. The spherical form of the granules is ac- 
quired by allowing them to fall into a shallow iron pan held over a 
fire. Sago is made with milk, cream, and eggs into nutritious pud- 
dings, and it may be used to thicken broths and soups of various 
kinds. It has an agreeable flavour, somewhat more delicate than 
tapioca, and is an invaluable adjunct to the invalid dietary. 

Iceland Moss (Cetraria Islandica) is a lichen sometimes employed 
as food after purifying it by washing. It contains at first various 
bitter principles, which "must be eliminated. It can be made into 
bread or used as an ingredient of blancmange, etc. It has been 
recommended by Senator and others for use by diabetics to replace 
ordinary bread, and it makes a convenient vehicle for the adminis- 
tration of fats, such as bone marrow (Walker). It also forms a good 
demulcent decoction. 

Several forms of seaweeds are used as food by the Japanese,. 
Siamese, and Polvnesians. 



Starchy Foods for Children 

The best cereals and other starches for children are rice, hominy,. 
Indian meal, barley, oatmeal, cracked wheat or wheaten grits, farina, 
cornstarch, and sago. 

When the cereal grains are used instead of flour, they should be 
soaked in cold water for five or six hours and then cooked for two 
or three hours in a double boiler. If fed to infants less than two 
years of age or to children with any gastro-intestinal disorder, they 
must be thoroughly strained. They should be salted and served 
with cream, but without much sugar. The steamed preparations 
of oats, wheat, etc., which are sold in market, may be boiled one 
hour, and otherwise treated as the grains. 

Bread and crackers may be allowed to infants after the first 
year, but only with their meals. The bread should always be porous, 
well baked, and stale. It may be toasted, or given dry in milk, or 
moderately buttered. Zwieback and plain rusk are also good foods 
for young children. 

Crackers are made in great variety for children who have passed 
the second year. They should not be too dry or hard. They may 
be eaten in milk or with beef juice, or separately, with meals only. 



ATE VI 



"':} 






MARUNTA 




POTATO 






i" 



9 



\ 



L..i>^ 



GINGER 



rtfe 



€ 



it 









SAGO 



^fip 





B 




PEAS BEANS 

STARCH GRANULES, MAGNIFIED. 

(From- Bulletin No. 13, Division of Chemistry, United States Agricultural Bureau . 

DRAW N Rl iiK(i. MARX. 



VEGETABLE FOODS I 59 

The best are those made of wheaten or Graham flour, oatmeal, or 
gluten. The latter are the least palatable. 

A large variety of prepared cereal foods are sold and recom- 
mended especially for children's use. These foods have been con- 
verted by heat or malt to dextrin and glucose or maltose, but they 
often contain a deficiency of flesh formers, and should never be long 
relied upon for feeding young infants to the exclusion of more natu- 
ral food. (See Prepared Farinaceous Foods, p. 146.) 

Diastase, Malt Extracts, etc. 

Diastase is a vegetable ferment which has the property of con- 
verting starchy foods into a soluble material called maltose. It is 
soluble in water and weak alcohol, insoluble in stronger alcohol. Its 
advantage, as compared with similar ferments in the saliva and pan- 
creatic juice, is considerable, and its strength enables it to dissolve 
starches when present in the proportion of only 1 to 2,000. Like the 
above-named ferments, it acts in alkaline solution, but, unlike them, 
it continues to operate in acid media ; hence its action is not dis- 
turbed by the gastric juice. Diastase is the peculiar substance which 
causes the ripening during germination of fruits and vegetables by 
converting their starches into dextrins and sugars. Hence fruit 
becomes more and more digestible as it ripens. 

In prescribing diastase or malt extract it should be remembered 
that the ferment is precipitated and destroyed by alcohol of even 
moderate strength, and also by salicylic acid, which is antagonistic 
to it. 

When malt is added to a pease pudding or other mashed vege- 
table, it separates the mass into a paste of cellulose and vegetable 
casein, with a supernatant solution of dextrin. 

Williams recommends the use of malt flour with cereal foods to 
render them more digestible. Malt flour alone is too sweet, but, 
added in the proportion of one part to four or eight of oatmeal, it 
makes an excellent light, thin porridge for invalids. 

A variety of malt extracts and malted foods are prepared for in- 
valids, and many of them possess intrinsic value for nutrition and 
tonic action. They are especially useful in chronic and subacute ail- 
ments and convalescence from protracted fevers. They are benefi- 
cial in tuberculosis, caries, chronic abscess, neurasthenia, the scrofu- 
lous diathesis, typhoid fever, and to some extent they can be used 
as beverages to replace the stronger malt liquors, ale, beer, etc., for, 
according to Leeds, they always contain above 3 per cent of alcohol. 

All malted foods are deficient in fats and protein. Farinaceous 
meal of any kind mixed with one eighth of its weight of ground 
malt forms a highly digestible combination. Even 20 per cent of 
meal can be used, and the preparation still keeps fluid (Roberts). 



l6o FOODS AND FOOD PREPARATIONS 

Kepler s Extract of Malt is given in the dose of a teaspoonful 
after meals in milk or soda water, or it may be spread upon any form 
■of starchy food. 

Loeflund's Malt Extract is given in doses of a dessertspoonful 
after meals in a gobletful of milk. 

Maltine is made from three cereals — barley, wheat, and oats. It 
is rich in diastase. It may be added in equal part to wheat or barley 
flour which has been previously boiled in water, and the mixture 
may be used as a diluent of milk. Maltine may be taken after meals, 
either plain or added to cod-liver oil, coca wine, pancreatin, hypo- 
phosphites, etc., for use in tuberculosis and other diseases. 

HofF's Malt Extract is given in doses of a wineglassful or more 
with meals for adults, and one or two tablespoonfuls for children. 
It contains considerable diastase, a minimum of alcohol (about 2 
per cent), and is said to be free from noxious ingredients. It may be 
drunk warmed, with a lump of sugar added, as a soothing draught 
to allay cough. If desirable for feeble stomachs, it may be diluted 
with water or soda water. 

Trommers Diastatic Extract of Malt is composed of the soluble 
ingredients of Canada barley malt. It is of a sirupy consistence 
and has a sweetish taste, which some patients object to, while many 
prefer it. The sweetness may be lessened or disguised by dilution 
with water, hot milk, brandy, whisky, or rum. It is advisable, if the 
stomach is feeble, to give teaspoonful doses at first, to be increased 
to a tablespoonful three times a day after meals. 

Pancreatic extract or three to five grains of pancreatin with five 
grains of sodium bicarbonate may be added to a cupful of thick, well- 
boiled farinaceous gruel of any sort — oatmeal, cornstarch, etc. — 
and if kept at ioo° F. for a few minutes, the mass is soon liquefied 
and made digestible. The hydrated starch has been converted into 
dextrin and sugar. There is little or no alteration produced in taste, 
and if starch is to be given to an infant under a year old for any 
purpose, it may be prepared in this manner. 

Vegetable Food 

Nearly all the great divisions of the vegetable kingdom afford 
wholesome food for man. 

Vegetable food eaten in large quantity increases the elimination 
of carbon dioxide from the lungs. It also makes the urine alkaline 
and intensifies the alkalinity of other secretions. The urine of her- 
bivorous animals is normally alkaline when they are well fed, but 
during prolonged fasting it becomes acid. The nursing calf when 
taking only animal food from the mother passes acid urine, but after 
weaning, when the animal changes to a vegetable diet, the reaction 
becomes alkaline. 



VEGETABLE FOODS l6l 

The chief vegetable proteids are vegetable albumin, vegetable 
casein or legumin, and gluten. The latter predominates in the cerea- 
lia, and the legumin is principally found in pulses. These proteids 
are less rich in nitrogen than the corresponding animal albuminates. 

Many vegetables contain tough cellulose, and at best not over 50 
per cent of this material is digested and assimilated in man, although 
the lower animals derive much more nutriment from it. 

A purely vegetable diet is not economical for a labouring man, 
for the reason that to derive sufficient nitrogenous substance from it 
he must either obtain the very best and most expensive cereals or 
legumes, or he must eat a very large quantity of vegetables. (See 
Vegetarianism, p. 35.) By the addition of albuminous food or fat 
to his diet he saves both expense and wear and tear of his digestive 
organs. If unable to obtain fresh meat, he may employ for this 
purpose milk, bacon, lard, dried fish, such as herring or cod. Among 
vegetable foods oatmeal and beans will furnish him with the largest 
available proportion of nitrogenous material. Vegetables, except 
those which are really seeds, such as those of the leguminosse or 
pulse tribe, contain but little fat. 

A strict classification of vegetables is impossible in these pages. 
Green corn is certainly a vegetable, but it is more conveniently 
described in connection with cornmeal, samp, etc., among the cereals. 
(See Maize, p. 153.) 

Certain vegetables are classed as " green vegetables," meaning 
the lighter kinds of vegetables which contain considerable earthy 
salts and comparatively little starch, like spinach and lettuce, in dis- 
tinction from heavy vegetables which contain much starch, like pota- 
toes, beans, etc. The former term is used to describe fresh garden 
vegetables of all kinds in distinction from those which, like potatoes 
or onions, may be kept for some days or weeks without spoiling. 
The name is, however, too vague for accurate description. 

" Greens " is the common name given to such vegetables as 
spinach, lettuce, beet tops, etc., which contain much chlorophyll and 
little starch or sugar, and which are eaten soon after being taken 
from the garden. 

A simple division of vegetables for patients is (a) those the edible 
portions of which grow above ground and (b) those which grow 
below ground. With few exceptions, like the legumes, corn, and 
cabbage, the heavier vegetables — i. e., those which require more 
digestive power, and which contain abundant starch or sugar — grow 
below ground, or are tubers. Those which grow above ground are 
more digestible when fresh and young. 

Celery, however, is not a tuber, is not especially " starchy," and 
yet grows, in part, at least, beneath the earth ; so it is best in all im- 
portant cases to specify by name the individual vegetables which can 
be partaken of rather than to describe them in general classes. 



l62 FOODS AND FOOD PREPARATIONS 

Many vegetables, in themselves difficult of digestion, may be 
made less so by conversion into well-cooked purees, or their extracts 
can be used for flavouring broths and soups for invalid use. Gener- 
ally speaking, dried vegetables are much less digestible than when 
fresh. They become hard, stringy, and tasteless. 

The following-named vegetables are those in common use which 
contain the largest percentage of both starches and sugars : Pota- 
toes (both white and sweet), yams, beans, lentils, corn, peas, carrots, 
parsnips, beets, turnips. 

Vegetable foods which are somewhat stimulant or pungent in 
their action are leeks, onions, garlic, herbs in general, mustard, 
cresses, mints, asparagus, and radishes. They increase the secretion 
of the saliva and gastric juice, and several are somewhat diuretic. 

Some vegetables are laxative on account of their special chemical 
composition. Such, for example, are spinach, tomatoes, and most 
green vegetables when fresh and well cooked. Some, like cucum- 
bers, are laxative from the seeds, or, like old corn, from the indigesti- 
ble residue which they contain. The heavier vegetables, such as 
peas, beans, turnips, potatoes, etc., are liable to be constipating, al- 
though they aid normal peristalsis in that class of cases in w T hich the 
diet has been previously mainly nitrogenous. (See Dietetic Treat- 
ment of Constipation.) 

Vegetables which have a special antiscorbutic reputation are cab- 
bage, tomatoes, and all those used for fresh salads. These also fur- 
nish calcium oxalate in the urine. 

All vegetables which are eaten raw should be thoroughly washed 
beforehand ; otherwise they may be contaminated with manure and 
other impurities, or the excrement of domestic animals which have 
been roaming in the garden. The larvae of both tapeworms and 
roundworms have been transmitted to man in this manner. Water 
from foul wells is sometimes used for sprinkling gardens, and it is 
possible for typhoid, cholera, or other noxious germs to be spread 
by this means when the vegetables are eaten raw. 

Legumes 

Peas, Beans, Lentils, Peanuts. — Legumes rank next to cereals in 
importance as vegetable food. In middle and northern Europe 
among legumes peas are preferred, but in Mediterranean countries 
the use of beans and lentils predominates. In this country both peas 
and beans are extensively eaten, the lentil very little. Owing to the 
exceedingly leathery external envelope which they possess when old, 
legumes are very indigestible unless cooked for a long time, and if 
dried they require previous prolonged soaking in cold water, for 
drying diminishes their size and makes them extremely tough. 
Fresh legumes contain much water, and in percentage composition 



PLATE VII. 




Bean Starch x 145 




Pea Starch x 145 
[From Bulletin No. 13, Division of Chemistry, United States Agricultural Buretu 



IH'Tn i:\ ' 1.1 KKiHMl It 1 ( II A RPSIIN . 



VEGETABLE FOODS : 1 63 

resemble the cabbage. They also contain much protein, carbo- 
hydrates, and a little fat. The proteid substance v. Liebig called 
" plant casein," from its resemblance to milk casein. It differs from 
the proteid gluten of grains and pea and bean flour and will not form 
dough or make bread. The percentage of protein in legumes ex- 
ceeds that of the best beef (M. H. Abel). Although the legumes 
contain so large a percentage of protein, it is by no means all assimi- 
lated. Hoffman found that nearly one half of the protein of lentils 
passed off in the feces, being unabsorbed. Striimpell found that 
40 per cent of the protein of whole beans — i. e., with the skins in- 
tact — is undigested ; but when made into flour only 8.2 per cent of 
protein was unabsorbed, the latter corresponding with the digesti- 
bility of meat protein. 

Legumes are liable to induce intestinal fermentation, with exces- 
sive and often annoying production of gas (methan), hence they are 
not available as the sole article of diet. If eaten as an exclusive 
food, eighteen ounces of dried peas or beans, making six pints of 
thick soup, would have to be consumed daily (M. H. Abel). 

Dried or " split " peas have had the external envelope removed, 
and they may be made into nutritious purees. The tough external 
coats of old peas may often be found wholly unaltered in the feces. 

According to Parkes, a pound of peas contains 168 grains of 
starch, and about 6.5 per cent of this food is wasted in the alimentary 
canal. 

Fresh very young green peas, petit pois, are easily digested, and 
may occasionally be allowed in a convalescent dietary, but old and 
tough legumes require more mastication even than meat. 

The legumes are often cooked with pork, which raises the per- 
centage of fat in this form of food and adds to their nutritive value. 
Baked beans are cooked in this way, and also pea soup ; the swelling 
starch granules mingle with the melting fat of the pork and make 
the dish more palatable as well as much more digestible than when 
this fat is added to meat in the form of croquettes or mince, when it 
merely smears the outside of the larger particles of food. 

Erbswurst, or pea sausage, was introduced some years ago in the 
German army. It was invented in 1870 by a cook named Griinberg, 
and the German Government bought the secret of its preparation. 
It is a cooked food composed of pea meal mixed with fat pork and 
salt, so treated as to prevent the decay of legumin. It is highly nu- 
tritious, for the peas contain a large proportion of nitrogenous as 
well as starchy material, and the fat furnishes energy, but as a diet 
it soon becomes monotonous, and not infrequently produces flatu- 
lence and diarrhoea, for which the legumes are noted. The flatu- 
lence is caused by liberation of sulphuretted hydrogen from a sub- 
stance called legumin. 

Erbswurst may be quickly made into soups. It figured largely 



164 



FOODS AND FOOD PREPARATIONS 



in the Franco-Prussian War, and was known as the " iron ration." 
A powdered " pea soup " may now be obtained which is composed of 
powdered peas and extracts of beef with salts and herb extracts for 
flavouring. A three-and-a-half-ounce package contains in grammes : 
proteids, 21 ; fats, 17.25 ; carbohydrates, 46.5. It is excellent for 
army service in the field. 

Composition of some Prepared Military Pea Foods (Woodruff) 





Water. 
12.09 


Protein. 


Fats. 


Carbo- 
hydrates. 


Wood 
fibre. 


Ash. 
6.15 

n-73 
13-53 

6.03 


Authority. 




3I.I8 
16.OO 
I5-70 
16.93 
15.81 

21.09 


3.08 

35- 00 

23.00 

8.98 

24.41 

17.25 


47-50 
27.OO 

53-44 
36.78 

46.45 


1-34 
1.69 

4.40 


Blythe. 
Parkes. 


as first used. . 
1887 


Dried pea soup (1) 

" " " (2) 

Kopf's " " (used by 
the English army). . . . 


7.58 
8.08 

4.78 


Konig. 

S. P. Sharpless. 



Penzoldt has succeeded in obtaining predigested vegetable albu- 
min by the following receipt : 

Finest pea meal 250.0 grammes. 

Pepsin 0.5 gramme. 

Salicylic acid 1 . o " 

Mix and let stand at ioo° F. for twenty-four hours ; strain. 

The fluid retains the taste of pea soup, and is quite free from 
starch. It may be added to meat extracts or eggs, and may be fla- 
voured with salt, pepper, and spices. 

Haricots or kidney beans constitute a very serviceable article of 
diet, being one of the cheapest and best of all the pulses. These 
beans must be thoroughly soaked until swollen and soft before boil- 
ing, and should be only eaten when wholly tender. Their flavour 
is heightened by the addition of a little onion, parsley, or other 
aromatic vegetable, and their nutritive value is increased by cooking 
them with pork. 

Fresh, young, and tender string beans are very digestible. 

Young, fresh Lima beans are wholesome and very nutritious, but 
if old they are indigestible. 

The red bean of the tropics, which is largely used in the Mexican 
army ration, is less prone to cause diarrhoea than the dry domestic 
white bean ; but it has a more tender skin, is therefore less easily 
transported, and it absorbs moisture so rapidly that it is liable to 
ferment. 

The frijole is a small, flat, reddish-brown bean much eaten in 
Mexico and neighbouring portions of the United States. 

The soy bean is the chief legume of China and Japan, where it 
furnishes the necessary protein to add to a rice diet. From its vege- 
table casein several varieties of bean cheese are made. 



PLATE VIII 




Potato Starch x 43 




Potato Starch 
(trom Bulletin So. IS, Division of Chemistry, United States Agricultural Bureau) 



'HMTO l!Y 1 1.1 1 Hi 'K 1> RICHARDSON. 



VEGETABLE FOODS 165, 

Lentils. — Lentils are much cultivated in the south of France, and 
also near Paris. They are usually dried and split, in which condition 
they make a nutritious soup. They are used more on the Continent 
of Europe than in this country, and they are eaten in England, 
usually in the form of puree. Lentil flour contains twice as much 
protein as that of oats or wheat, and nearly twice as much lime 
(Roberts). The Hindoos rely upon the lentil for its staying power 
when undertaking arduous journeys. 

Lentils are sold under the name of " rcvalenta Arabica " of which 
they form an ingredient (p. 157). Their taste is somewhat bitter, 
and on that account, unless disguised by some vegetable flavour, they 
may be disliked. Like the other legumes, they contain protein and 
fat, and are nutritious. 

Peanuts. — The peanut is not a nut at all, but a legume growing 
under ground. It resembles nuts, however, in its large content of 
fat — 50 per cent. 

Peanuts are nutritious, but indigestible when roasted whole. 
Peanut flour is made from the ground and bolted nuts, and it is 
claimed that a pound of it contains as much nutritive material as 
three pounds of beef or two of peas. The peanut grits may be 
boiled like oatmeal or made into biscuits. Experiments have been 
made with the view of possible introduction of this food into the 
German army to be used like the Erbswurst of fame in the Franco- 
Prussian War. Peanuts contain considerable oil, which is extracted 
and sold largely as spurious olive oil. It is also sometimes used in 
the preparation of oleomargarine, and the roasted nuts themselves 
make a sort of imitation coffee. A form of peanut meal is prepared 
for diabetics which is said to contain little or no carbohydrate. 
Pancakes may be made from it. The meal contains 52 per cent of 
protein, 27 per cent of carbohydrates, and 8 per cent of fat. Four 
million bushels of peanuts are raised annually in the Southern States 
of this country. 

Roots and Tubers 

Roots and tubers constitute a very important class of vegetable 
foods. They contain both starch and sugar as well as a little pectin 
and potash salts. They have much less albuminous material than is 
to be found in any other forms of starchy food, and they also hold 
a large percentage of water. Many of them are very nutritious 
and even fattening, but in proportion to their bulk they afford less 
actual nutriment than either the legumes or cereals. 

Potatoes. — The potato ranks first in importance among the class 
of tubers which serve man for food, both on account of its easy cul- 
tivation in a great variety of soils and on account of its digesti- 
bility when properly cooked. As an exclusive article of diet the 
potato is too largely composed of starch to be of much nutritive 



1 66 FOODS AND FOOD PREPARATIONS 

value, and enormous quantities have to be eaten (several pounds a 
day) in order to supply enough nitrogen for the energy of the body. 
The potato, however, has less starch than rice, peas, or lentils. It 
also has less woody fibre than most underground vegetables. In 
Ireland this vegetable constitutes a greater proportion of the daily 
food than in almost any other country, and in periods of famine 
has been known to form four fifths of the entire food for a time, 
but of late years it has been largely supplemented by the culti- 
vation of Indian corn and other products. The flavour and quality 
of the potato is influenced very much by the soil and climate in 
which it grows, a sandy soil being best. 

Konig gives the percentage composition of the potato as water, 
75.77; nitrogenous materials, 1.79 (others give 2.10); fat, 1.60; 
starch, 20.56 ; cellulose, 0.75 ; ash, 0.97. It is thus seen to contain 
about one fourth solid matter. 

The potato becomes a much more strengthening food when 
eaten, as it usually is, with meat gravy, fat, or butter and salt. 

Potato juice has a faintly acid reaction, and its vegetable acids 
are mainly combined with salts of potassium, but also with sodium 
arid calcium. It also contains traces of iron, phosphoric and sul- 
phuric acids, chlorine, silica, and magnesia. Owing to the large 
proportion — from 12 to 24 per cent — of nearly pure starch which 
is found in the potato, it is very extensively used in this country and 
elsewhere for the manufacture of laundry starch. Old potatoes, and 
those which have been long kept, show some alteration in the quan- 
tity of their starch, and a part is converted into sugar and gum. 

Potato starch, as compared with other starches, is thoroughly 
digestible, but much depends upon the cooking. The starchy gran- 
ules are tough and absorb water from the acid juices which surround 
them and from water added in cooking, and when properly prepared 
the potato becomes soft and mealy. When this is not the case, how- 
ever, it remains hard and soggy, and is thoroughly indigestible. 

The following statement in regard to the potato is made in a re- 
cent report of the British Commissioners of Prisons : 

" Within and surrounding the cells is a fluid or juice the albumi- 
nous constituents of which are coagulated during the process of 
cooking. The watery part of this juice is absorbed by the starch 
granules, which swell up and distend the cells in which they are con- 
tained, so that they no longer adhere together, and the result is the 
loose flocculent mass which is described as a floury or mealy potato. 
Unless the potato be properly cooked, the fluid referred to is only 
partially absorbed, the cells do not become sufficiently distended and 
separated, and the potato is then described as ' waxy ' and ' dense.' 
In this condition it is not digested, and consequently does not fur- 
nish to the system the antiscorbutic principle in which resides its 
chief value as an article of diet." 



VEGETABLE FOODS I 67 

When potatoes are cooked in water, it is desirable not to remove 
their skins, for the latter prevent to a great extent the passage of 
the salts out into the fluid. The fact that potatoes will not decay if 
kept dry for a length of time makes them very useful vegetables 
upon sea voyages, when their antiscorbutic properties are especially 
serviceable. 

Potatoes are more digestible when cooked by baking in their 
skins than by any other process. They then become mealy and their 
starch is digested with comparative ease by invalids. They are also 
quite digestible if steamed, or if boiled and mashed through a 
colander. 

Potatoes must be avoided in all cases of feeble digestion unless 
they are perfectly mealy and crumble readily, and this quality de- 
pends not alone upon the method of cooking, but upon the nature of 
the potato itself, which varies according to the soil or the season of 
the year in which it has been grown. Very young potatoes are not 
mealy. They require more cooking and are less digestible than 
those of medium age. If too old, on the other hand, potatoes be- 
come waxy and equally undesirable. If they have been exposed to 
frost or have been cultivated in a damp, boggy soil, their digestibility 
is much impaired. 

Sweet Potatoes. — The variety known as the sw r eet potato contains 
somewhat less starch than the white potato, having but 16 per cent, 
but it has more water, and a larger proportion of sugar — 10 per cent. 
It forms a valuable and decidedly nutritious food which is eaten ex- 
tensively throughout the United States, but it is not so digestible as 
the white potato, for it cannot always be obtained in a mealy form, 
and is sometimes stringy and sodden. A flour or meal can be pre- 
pared from it by drying. Its use in Europe antedates that of the 
white potato, which has to a great extent superseded it. These po- 
tatoes vary much more in flavour than do the white. In general, 
they should not be given to invalids. 

The yam, another form of tuber, is eaten in the tropics and in 
some parts of Europe. It is mealy, but not very sweet, and it con- 
stitutes a wholesome and thoroughly digestible food. 

The Jerusalem artichoke, or ground pear, is a tuber belonging to 
the sunflower family, which was originally introduced from Brazil. 
It is used more commonly in England than elsewhere, but is also 
sometimes cultivated in the United States. It is sweet and watery, 
for it contains little starch, and it is not " mealy " when cooked. It 
contains more sugar than the sweet potato, having 14 per cent of 
sugar, 3 per cent of nitrogenous material, and 2 per cent of inulin 
(Yeo). Its nutritive value is comparatively slight, but it is easily 
digested. 

The Beet contains among its solid ingredients between 85 and 
90 per cent of starches and sugars, a trace of salts, and somewhat 
13 



l68 FOODS AND FOOD PREPARATIONS 

over i per cent of proteid matter. It is a common source of sugar, 
which when refined is sometimes less sweet than cane sugar, but is 
otherwise as good. On account of the sugar which they contain, 
beets have the reputation of contributing to the formation of fat 
in the body. Young, tender beets are very nourishing, and they 
are often eaten in the form of salads or with vinegar and oil, and 
thus contribute a useful variety to the diet. 

Succulent Tubers. — There is a group of succulent roots which 
contain considerable watery juice, and on this account are usually 
eaten fresh, for if kept long they become dry and less palatable, or 
are apt to decay ; with care, however, they may be preserved in their 
natural state for a considerable period. They are very digestible, 
and when thoroughly boiled are nutritious. They are carrots, pars- 
nips, turnips, salsify, and radishes. 

Carrots consist of upward of 85 per cent of water, with a small 
proportion of salts, 8 per cent of carbohydrates with some sugar, and 
about 1 per cent of protein. The outer layers of the carrot contain 
a material called pectin that can be obtained as a jelly and mixed 
with fruit or meat jelly for flavouring invalid diet. 

Young carrots, when soft and friable, if boiled are very tender 
and highly flavoured, and constitute a nutritious food. In France 
and Germany they are more popular than in this country and are 
cooked w T ith other vegetables, although somewhat at the expense of 
the flavour of the latter. At the baths of Vichy they form a part of 
the daily breakfast. 

Parsnips contain the sugar of starch with a large percentage of 
water, and they are sometimes fermented into an alcoholic beverage. 
They are a wholesome although less used food than carrots. The 
parsnip contains over 90 per cent of water and only 6 per cent of 
starch and sugar, with 1 per cent of protein, besides other materials. 
It is a rather strongly flavoured vegetable, and bulky in proportion 
to its nutritive value. It is extensively used for feeding cattle, and 
when young and properly cooked by prolonged boiling and season- 
ing it is a good food. It should be particularly avoided by those 
persons in whom there is any tendency to flatulency, which, like the 
legumes, it is apt to produce. 

Turnips are less nutritive than either carrots or parsnips. They 
should never be eaten by the sick. 

Kohl rabi, or turnip-root cabbage, yields an overground turnip, 
which is somewhat astringent. 

Salsify, or oyster plant, is a root which has a mild sweet flavour 
somewhat similar to the parsnip, and is an excellent food of easy 
digestibility. 

Radishes, which are not unlike turnips in composition, contain a 
large percentage of water and a comparatively small amount of 
starch. This vegetable is of no special value for nutrition, and serves 



VEGETABLE FOODS 169 

chiefly as a relish. Being usually eaten raw, it is difficult of digestion, 
and is apt to produce eructations. It is rendered more digestible by 
cooking. It has some reputation as an antiscorbutic. 

Green Vegetables 

Composition. — Green vegetables do not contain much nutriment 
in comparison with the cereals and tubers, and they are mainly useful 
for furnishing a pleasing variation in diet and for supplying a large 
proportion of salts and some acids which are believed to be service- 
able in the prevention of scurvy. The various uses of the salts have 
been elsewhere described (see p. 45). These vegetables often con- 
tain 90 per cent or more of water, which in itself is useful to the 
system in many ways. They furnish only a small quantity of nitro- 
genous material, which varies from 1.5 up to 4 per cent. In addition, 
they contain cellulose, chlorophyll, sugars, gum, pectin, and some- 
times a little fat. Their variety of taste depends upon the presence 
of flavouring materials, chiefly essential oils. As a rule, they have a 
better flavour, and are more digestible when young than old, when 
they become tough and " stringy " from a relatively large percentage 
of cellulose or woody fibre. Since the green vegetables afford so 
little nutriment in proportion to their bulk, they are not of much 
service for persons with feeble digestion, and, unless they are young 
and tender, they are positively harmful by overtaxing the digestive 
system and irritating the alimentary canal. On the other hand, they 
are very useful in overcoming constipation by their bulky waste 
matter, which acts as a mechanical stimulus to peristaltic action and 
promotes movement of the bowels. 

The digestibility of these vegetables is rendered much greater by 
careful cultivation in suitable soils. Owing to the large quantity of 
water which they hold (which readily evaporates), they soon wilt or 
become dry in market. For the most part they should be eaten when 
quite fresh, although celery and winter cabbage form an exception 
to this, as they may be kept for weeks. 

Fresh green vegetables as well as roots or tubers are always made 
more digestible by cooking, which softens them. Their most diges- 
tible form for invalids is that of purees. 

Cabbages. — The cabbage family, which belongs to the natural 
order Crucifercu, furnishes many examples of green vegetables, some 
of which are of value for their leaves, and others for their modified 
flowers. There are about seventy varieties of cabbages. They con- 
tain considerable sulphur, which, if malfermentation exists in the 
alimentary canal, produces sulphuretted hydrogen, causing flatulence 
and unpleasant odour. They may also give rise to calcium oxalate 
in the urine, by causing indigestion, and they should be avoided by 
the rheumatic or gouty, and, in fact, by all classes of invalids. Cab- 



170 FOODS AND FOOD PREPARATIONS 

bages and other vegetables of this order impart a strong taste and 
odour to the water used for boiling them. When soft and crisp, 
cabbage is a wholesome food for those with strong digestion, and 
it has decided antiscorbutic properties when fresh, which are less- 
ened by fermentation. 

The principal edible representatives and preparations of the cab- 
bage family are the following : 

1. Sauerkraut is made by placing salt between layers of cabbage 
leaves and subjecting them to pressure, which bruises them and 
squeezes out their juices. The mass then ferments with the forma- 
tion of organic acids. 

2. Cauliflower and broccoli are the flowers of plants which are 
grown large and tender by cultivation. When boiled and served 
with a milk sauce they are much esteemed for their flavour and easy 
digestibility in healthy stomachs, but they cause flatulence if eaten 
by dyspeptics. These vegetables may be dressed with olive oil and 
eaten as a salad. 

3. Cole is a plant of the cabbage family which does not " head." 

4. Seakale is grown in the dark, so that it has no chlorophyll. It 
is equally digestible with cauliflower if well bleached. It is more 
often cultivated in England than in this country. 

Spinach, beet tops or " greens," dandelion tops, and turnip tops 
are all useful green vegetables, and of these spinach, which is slightly 
acid, is the most common and desirable. These substances afford 
almost no nutriment, and are valuable chiefly for their laxative action. 
The mineral salts which they contain, especially those of spinach, 
have been shown by Luff, of London, to be of positive value in gout 
in increasing the solubility of sodium biurate and retarding the con- 
version of quadriurates into biurates. (See Goutr) If the leaves 
are young and tender, and if they are cooked until they become 
quite soft and are then chopped into a fine pulp, they are very whole- 
some articles of food for the relief of chronic constipation. The 
dandelion leaves have a less delicate flavour than spinach, and are 
said to possess a slight diuretic action. Unless bleached they are 
bitter. The dandelion root is laxative, like the leaves, and it forms 
an ingredient of root-beer. 

Lettuce, etc. — There is a group of vegetables of which lettuce is 
the chief type, the leaves of which are eaten raw. They are useful 
for their flavour and for the variety which they furnish in the course 
of a meal. They cannot be said to possess any nutrient value, but 
they are usually taken with vinegar and oil, and the latter is very 
nourishing. Since they contain little starch and practically no sugar, 
they may be allowed in the diabetic regimen. 

Sorrel and cress, or peppergrass, are used in the making of salads, 
but less in this country than in Europe. Sorrel has a somewhat pun- 
gent or acid flavour, which is due to acid oxalates, and this fact ren- 



VEGETABLE FOODS 171 

ders it unfit for use by patients who are subject to attacks of gout 
and rheumatism or who have the uric-acid diathesis. A fatal case of 
sorrel-poisoning in a boy five years of age has been reported. To 
quench thirst, excited by eating a quantity of sorrel, he swallowed 
some soapy water, the alkali of which produced a soluble oxalate. 
A quantity of oxalic acid was found in the stomach. 

Many other substances are mentioned in works on dietetics which 
are used in the making of salads or pickles and as relishes. They are 
antiscorbutic and serve to stimulate the digestive secretions and give 
a fillip to the appetite. Such are green peppers, capers, mint, tarragon 
(an aromatic Siberian plant), parsley, chervil, endive, chicory, okra. 

Celery is a wholesome vegetable when cooked in milk until it is 
quite soft ; but eaten raw it is stringy, and, as it has but little nutri- 
tive value, its use in that form should be discarded by invalids. Its 
aromatic flavour makes it very popular, and it furnishes a useful 
addition to a light luncheon with bread and cheese. It has acquired 
an undeserved reputation for use in rheumatism. " Celery salt " is 
an agreeable flavouring substance for soups and salads. Various 
preparations are made from the plant, which are sold by druggists as 
hypnotics. They are of no value. 

Artichokes are a variety of thistle. They contain tannin and mu- 
cilaginous materials, but nothing of true nutrient power, although, 
according to Moleschott, they hold 17.75 P er cent °f organic matter. 

Green artichokes when tender and thoroughly cooked are easily 
digested, but their cost in this country prevents them from being 
consumed except as an article of luxury. They may be given to 
some diabetic patients among the few vegetables which they can eat 
with impunity. Eaten raw, as they sometimes are in France, they are 
very indigestible. 

Tomatoes. — The tomato is a vegetable which was introduced into 
this country about sixty years ago, the value of which is becoming 
more and more appreciated. In Germany it is still sold as a fruit of 
luxury rather than as a common vegetable. It is wholesome when 
eaten raw as a salad with vinegar and oil, and it forms a popular in- 
gredient of strong condiments, such as tomato catsup. It is refresh- 
ing, slightly acid, and easily digested. The oxalic acid which it con- 
tains makes it injurious in cases of gout or the uric-acid diathesis. 
The tomato is much prized as a canned vegetable on account of the 
fact that it retains more of its original flavour than do most vege- 
tables preserved by this process. 

The eggplant is related to the tomato, and like it contains many 
seeds when full grown, but it is much less digestible, especially when 
fried, and is not a suitable food for invalids. 

Cucumbers are mainly eaten raw, and they should be young. Like 
celery, they contain too much woody fibre to be consumed in bulk. 
They are valuable for pickling in vinegar or in the making of chow- 



172 FOODS AND FOOD PREPARATIONS 

chow, but they are always indigestible ; this is due in great part 
to the large size of the seeds which the vegetable contains, and it 
should never be eaten by any one excepting those having vigorous 
stomachs. Eaten raw, even in small quantities, it may produce vio- 
lent colic and diarrhoea. 

Asparagus is a vegetable possessing a very delicate flavour, and 
from the fact that it is among the first of the fresh vegetables to ap- 
pear in the early spring it is highly esteemed. When young and 
tender it is very digestible, even for invalids. The green asparagus 
contains more bitter and resinous principles than the white. It has 
been claimed that it possesses some influence as a cardiac sedative 
as well as aphrodisiac action, but these properties are imaginary. It 
is, however, slightly diuretic, and it owes this influence to a substance 
called asparagin, which may be obtained in crystalline form. Aspara- 
gus imparts a very strong and disagreeable odour to the urine which 
I have known to appear within an hour after it has been eaten, and 
which persists from twelve to twenty hours. It is caused by a vola- 
tile sulphur product, a methyl mercaptan, which has been proved to 
originate in the intestine during digestion, from whence it is absorbed. 

Rhubarb, or " pieplant," the stems of the leaves of which are 
eaten stewed, is an excellent vegetable. The flavour is quite tart, 
and the fibre is stringy, but thorough cooking renders it soft and 
digestible. It is laxative, and is therefore useful in cases of chronic 
constipation. This wholesome vegetable has not received the atten- 
tion it deserves. In Germany, for instance, it is still grown merely 
as an ornamental garden plant on account of its large showy leaves. 
It produces calcium oxalate in the urine if eaten in excess, and must 
therefore be avoided in oxaluria, gout, and rheumatism. 

Pumpkins and squash contain much water and a good deal of 
coarse fibre. Tender and young summer squash is fairly digestible, 
but presents no special dietetic advantages. The pumpkin is one of 
the oldest vegetables on this continent, for it was grown extensively 
together with maize by the early Indian tribes. 

Onions, garlic, shallots, and leeks, which are edible both as fresh 
vegetables, and after long keeping, are useful as condiments for fla- 
vouring salads, meat stews, and other foods. They are also eaten 
independently for their nutritive properties, which are somewhat 
greater than those of the four or five vegetables last considered. 
Tender young leeks and white onions boiled and served with milk or 
cream are very wholesome and of delicate flavour. They possess, in 
common with the other green vegetables, a moderate laxative action, 
and are antiscorbutic. They impart a strong typical odour to the 
breath, which appears within two or three hours, and if constipa- 
tion exists, persists for twenty-four hours or more. This is due 
to volatile substances which are absorbed by the blood from the ali- 
mentary canal and carried to the lungs, where they are liberated. 



VEGETABLE FOODS 



173 



Vegetable marrow is a highly succulent vegetable, somewhat re- 
sembling the pumpkin. It possesses an agreeable flavour, but con- 
sists so largely of water that it is of scarcely any use as food. 

Cranberries are really more of a fruit than a vegetable, but they 
are usually eaten with meat as a vegetable. They are serviceable 
for their agreeable acidity and flavour, but unless very thoroughly 
cooked and made into a jelly with much sugar, they are indigestible, 
for their outer coatings are extremely tough. They should never be 
given to invalids. 

The composition of some common vegetables is thus tabulated 
■by Moss : 

Composition of Vegetables 



Constituents. 


Potato 

(Payen). 


Potato 
(Lethe- 

by). 


Sweet 

potato 

(Payen). 


Jerusa- 
lem ar- 
tichoke. 


Carrots 
(Lethe- 

by). 


Parsnips 

(Lethe- 

by). 


Turnips 

(Lethe- 

by). 


Cab- 
bage. 


Nitrogenous matter 


2.50 
20.00 
I.04 
I.09 
O.II 
1.26 


2.1 

18.8 

3-2 
0.2 
O.7 

75-o 


I.50 
16.05 

0.45 
I0.20 
O.30 
2.60 
l.IO 

67.50 


3-1 

1-5 

14.7 

0.2 

i-3 

O.q 

0.4 

1.9 

76.0 


I 
8 



83 


3 
4 

2 





I.I 
9.6 

5*8 

o-5 
1,0 

82.0 


1.2 
5-1 

2.1 

o!o 

9I.O 


2.0 




(m 

0.5 
0.7 


Sugar and gummy matter 
Fatty matter 






Pectic acid 

Pectin 

Inulin 

Water 


74.^0 


91 .0 




Total 


IOO.OO 


100. 


IOO.OO 


100. 


100 





100. 


IOO. O 


100.0 











The following analyses of common vegetables have been made 
by Konig: 



Water 

Nitrogenous matters 

Fat 

Sugar 

Other non-nitrogenous ex 

tractives 

Cellulose 

Ash 



Carrots. 


Turnips. 


Beet root. 


Celery. 


Onions. 


88.32 


9I.24 


87.07 


84.09 


85.99 


I.04 


O.96 


1-37 


I.48 


1.86 


0.2I 


O.I6 


0.03 


0.39 


0.10 


I.90 


4.08 


o.54 


O.77 


2.78 


7.17 


I.90 


9.02 


II.03 


8.04 


0.95 


O.9I 


1.05 


I.40 


0.71 


0.7I 


0.75 


0.92 


O.84 


0.70 



Cabbage. 



89.97 
I.89 
0.20 
2.29 



2.58 
I.84 
I.23 



Water 

Nitrogenous matters 

Fat 

Sugar 

Other non-nitrogenous ex 

tractives. , 

Cellulose 

Ash 



Cauli- 
flower. 


Brussels 
sprouts. 


Spinach. 


Lettuce. 


Asparagus. 


90-39 


85.63 


90.26 


94-33 


93.32 


2-53 


4.83 


3-15 


1. 41 


I.98 


O.38 


O.46 


o.54 


0.3I 


O.28 


1.27 




0.08 




0.40 


3-74 


6.22 


3.26 


2.I9 


2-34 


0.87 


1-57 


0.77 


0.73 


I. 14 


0.82 


1 .29 


1.94 


I.03 


0.54 



French 
beans. 



36 

77 
14 

20 

82 

14 

57 



174 FOODS AND FOOD PREPARATIONS 

The two preceding tables differ slightly in detail, but no more 
than the average variation in percentage composition of the vege- 
tables when not grown under identical conditions. They agree as 
nearly as can be expected. 

Fruits 

Composition. — The varieties of fruits which are consumed in 
all countries are innumerable, and their uses are various. Sweet 
fruits no doubt largely composed the diet of primordial man, as they 
do of every savage tribe to-day living outside of the Arctic Zone. 

Speaking generally, fruits are composed largely of water with 
starches, sugars, a vegetable jelly called pectin, cellulose, and organic 
acids. 

Pectin is a carbohydrate substance found in ripe pulpy fruits. It 
enables fruit to gelatinise when boiled. Its properties and com- 
position are not thoroughly understood. 

The organic acids exist mainly in union with alkalies, forming 
compounds which are readily split up in the system, leaving the al- 
kalies free to combine as carbonates or phosphates. 

The most important acids are citric, malic, and tartaric, which 
exist in various quantities and combinations. 

Citric acid predominates in lemons, limes, and oranges ; tartaric 
acid in grapes ; malic acid in apples, pears, peaches, apricots, goose- 
berries, and currants. 

Among the least acid of the common fruits are peaches, sweet 
pears, sweet apples, bananas, and prunes ; moderately acid are straw- 
berries. The most acid of all are currants and lemons. 

Fruits contain a smaller proportion of earthy -salts than other 
foods. 

Certain fruits also hold a little nitrogenous material, chiefly as 
albumins, but, as a rule, the starches and sugars predominate, and 
the nutritive value of any fruit depends upon them chiefly. Most 
fruits contain too much water to constitute an economic diet if eaten 
alone. Some also contain a small quantity of fat and waxy matter, 
and most of them have more or less pigment. 

Fruits which are especially rich in flavour, and which exhale a 
pleasant aroma, owe these conditions to the various essential oils 
and compound ethers which they possess in considerable amount. 

Many fruits are only partially edible owing to the fact that they 
are composed of a pulp contained within an indigestible structure of 
cellulose or woody fibre. 

Fruits are commonly classified into stone-bearing fruits, pomes, 
berries, capsules, and pepos. Some, such as the date, the plantain 
and its variety, the banana, afford sufficient nutriment to amply sup- 
port life for a long time ; others, like the apple, are wholesome, but 
slightly nutritious ; while others again are of little value for nutri- 



VEGETABLE FOODS 



i/5 



tive purposes, and are mainly serviceable for their agreeable flavour 
to furnish variety in the diet. 



Composition of 


Fruits 


(Bauer) 










Apple. 


Pear. 


Peach. 


Grape. 


Straw- 
berry. 


Currant. 


Orange, 
o P „t 


Water 


83.58 
0.39 
O.84 

7-73 

5-17 
1.98 
0.31 


83-03 
O.36 
0.20 
8.26 

3-54 
4-3o 
0.31 


83-03 
O.65 
O.92 

4.48 

7.17 
6.06 
O.69 


78.18 

o-59 
0.79 

24.36 

1.96 
3.60 

o.53 


87.66 
I.07 
0.93 
6.28 

O.48 
2.32 
O.81 


84.77 
O.5I 
2.15 

6.38 

O.9O 

4-57 
0.72 


89.01 

0.73 
2.44 

4-59 

o.95 
1.79 

0.49 


Nitrogenous matters 

Free acids 


Sugar 


Other non - nitrogenous 
matters 


Cellulose and kernel 

Ash 



Co7nposition of Fruits (Yeo) 





Apple. 


Cherry. 


Raisin. 


Fig. 


Water 


27-95 
1.28 
0.82 
3.60 
42.83 
17.00 
4-95 
i-57 


49.88 
2.07 
O.30 

32.22 

14.29 

O.61 

I.63 


32.02 
2.42 
0.49 

54-26 

7.48 
1.72 
1. 21 


31.20 
4.OI 
I.44 
I. 21 


Nitrogenous matters 


Fat 




Sugar 


49-79 
4-5i 
4.98 
2.86 


Other non-nitrogenous matters 


Ash 







Fruits arranged According to the Proportions between Acid, Sugar, Pectin, 
Gum, etc. {Average). (Fresenius) 



Fruits. 



Plums 

Apricots 

Peaches 

Raspberries . . . 
Currants. . . . 
Blackberries . . 
Whortleberries 
Strawberries.. . 
Gooseberries . . 

Prunes 

Apples 

Sweet cherries. 

Grapes 

Red pears 



Acid. 



Sugar. 



I. 
I 

2. 
2. 

3- 
3- 
4- 
4- 
4- 
7.0 
11 .2 

17-3 
20.2 
94.6 



Pectin, gum, etc. 



3-i 
6.4 

11. 9 
1 
o 
1 
o 
o 
o 

4-4 
5-6 
2.8 
2.0 

44.4 



Fruits arranged in the Order of their Conte?it of Sugar {Average). 

(Moss) 

Peaches 1.6 per cent. 

Apricots 1-8 

Plums 2.1 " " 

Reineclaudes 3- 1 " 



176 FOODS AND FOOD PREPARATIONS 

Mirabelles 3 ■ 6 per cent. 

Raspberries 4-0 

Blackberries 4-4 

Strawberries 5-7 

Whortleberries 5-8 

Currants 6.1 

Prunes 6.3 

Gooseberries. 7 • 2 

Red pears 7-5 

Apples. - - 8.4 

Sour cherries 8.8 

Mulberries 9-2 

Sweet cherries 10 . 8 

Grapes 14 • 9 

Uses and Properties. — The uses of the different fruits may be 
summed up as follows : 

1. To furnish nutriment. 

2. To convey water to the system and relieve thirst. 

3. To introduce various salts and organic acids which improve 
the quality of the blood and react favourably upon the secretions. 

4. As antiscorbutics. 

5. As diuretics, and to lessen the acidity of the urine. 

6. As laxatives and cathartics. 

7. To stimulate the appetite, improve digestion, and give variety 
in the diet. 

8. As special " cures " for certain diseases, like the grape cure, 
although their specific action is very doubtful. 

In a study of the diet of women students at Lake Erie College in 
Ohio, made in 1900 by Isabel Bevier and Elizabeth C. Sprague, it 
was found that an increase in fresh fruit consumption, especially at 
breakfast, showed that more breakfast was eaten and it materially 
lessened the craving for sweets. 

Fruits which afford the most nutriment are the banana, date, fig, 
prune, and grape. This is due to the large proportion of sugar which 
they contain. 

Fruits which contain the most water are muskmelons, water- 
melons, oranges, lemons, limes, shaddocks, and grapes. 

The antiscorbutic value of fruits is illustrated particularly by cer- 
tain varieties which furnish abundant potash salts, as well as lime 
and magnesia. Among these are to be mentioned apples, lemons, 
limes, and oranges. 

The diuretic influence of fruits is in part due to their water, but 
chiefly to their organic acids and salts, which stimulate the circula- 
tion and probably also the activity of the renal epithelium. 

Fruit-eating lessens the acid of the urine or even makes it alka- 
line owing to decomposition of various alkaline salts in the blood or 
tissues, which are reformed into alkaline carbonate and, as such, are 



VEGETABLE FOODS I 77 

excreted. For this reason fruit is sometimes beneficial in lithgemia 
and allied conditions to prevent accumulation of acid urates. 

The laxative action of fruits is partially derived from indigestible 
substances, cellulose, seeds, etc., and also, no doubt, from the special 
influence of their organic ingredients, which in some instances is very 
striking. 

The best fruits to offset constipation are fresh apples, figs, 
prunes, peaches, and berries. Dyspeptics must be careful to avoid 
eating all hard skins, seeds, or coarse-fibred fruits. 

Fruit Ripening. — As fruit ripens it absorbs more and more 
oxygen, and the tannin and vegetable acids which it originally con- 
tained are altered, so that it becomes less astringent and acid. The 
starch is more or less completely turned into levulose or glucose, 
and soluble pectin is formed. The aroma and taste of ripe fruits 
depend upon the relative quantity of these different substances, 
together with various volatile ethers and oils. The sour fruits have 
either more acid or less sugar, and in the sweet fruits there is a 
preponderance of sugar which masks the acid taste. The more 
luscious the fruit, the more soluble sugars and special flavouring 
substances does it contain. 

The employment of fruits as a common article of daily diet is 
highly beneficial, and the improvements which have been made of 
late years in methods of culture and means of rapid transportation 
make some varieties of fresh ripe fruits, such as the orange and the 
banana, available in almost every climate in all seasons, while their 
increasing cheapness places them within reach of the poor. 

Fruit Poisoning. — While fruits eaten daily and in proper modera- 
tion are very wholesome, if they are eaten too freely, or if they are 
either insufficiently ripe or overripe, soft, and decomposing, they 
undergo malfermentation in the alimentary canal, and are almost 
certain to cause diarrhoea with colicky pains, cramps, and sometimes 
nausea and vomiting. Severe attacks of gastritis may, especially 
in children, be produced by indulgence in unripe apples, pears, cher- 
ries, berries, etc., and even fatal choleraic diarrhoea has been occa- 
sioned by the indiscriminate consumption of fruits which have 
strongly laxative action. After such fruit poisoning, emesis should 
be excited if the patient is seen in time, and otherwise, if free purga- 
tion has not occurred, it is advisable to give a dose of castor oil or 
other cathartic, to remove the irritating substances as soon as pos- 
sible from the alimentary canal. In bad cases, prolonged gastric 
fever may ensue. Some tropical fruits possess specific poisonous 
properties. 

When to Eat Fruit. — Cooked fruits may be eaten with any meal, 
but usually when fruit is eaten for special dietetic purposes its effect 
is always more pronounced if taken alone, either at the commence- 
ment of meals or, better, between them. One often observes 



178 FOODS AND FOOD PREPARATIONS 

patients who can obtain no laxative effect from apples, figs and 
other fruit eaten as dessert, but which taken at night into an empty 
stomach or an hour before breakfast, with a glass or two of cold 
water, has a very pronounced favourable influence upon the bowels. 

The poorest time for eating fruit is at the conclusion of a very 
hearty dinner at which considerable variety of food has already been 
consumed. Fruit in general is less wholesome when eaten out of 
its natural season. All fruits, such as berries, the seeds of which 
are eaten, are much less liable to produce intestinal irritation if taken 
with bread or other bulky starchy food. Raw fruit unless eaten at 
once after picking should be well washed. The skin and seeds of the 
larger fruits and of grapes are quite indigestible. 

Fruit Soups. — In Germany fruit soups are more in vogue for 
general use than in this country, and they are often prescribed in 
fevers when diarrhoea does not exist. Uffelmann directs that for 
making a fruit soup one part of fruit to four or five of water may be 
used, and Bauer recommends soups " made by boiling fresh or dried 
fruits with water, with or without the addition of sugar, lemon peel, 
etc., and freed from the solid residue by pressure." 

Dried Fruits can be eaten less abundantly than fresh fruits. Some 
of the dried fruits are wholly indigestible ; such are currants and 
citrons. Others, like figs or prunes, are wholesome, and raisins, 
sultanas, dates, etc., contain considerable nourishment. All these 
dried fruits are preserved in their own sugar (glucose), which forms 
a sticky, gummy, non-crystallised mass. Dried apples, peaches, 
prunelles, etc., are preserved simply by the evaporation of the excess 
of water which they contain. 

Dried " currants " are the berries of a vine cultivated in the 
Ionian Islands. The word currant is a corruption of Corinth. The 
fruit in its dried state is wholly indigestible. 

When dried fruits, such as figs or dates, have become too hard 
they may be softened and made more palatable by pouring boiling 
water over them and allowing them to soak for a few hours, or the 
fruit may be put into cold milk and brought to the boiling point 
over the fire. This method will soften them in a quarter of an hour. 

A simple fruit diet which has been advocated for the cure of 
obesity and other ailments is the following : Three meals a day are 
eaten, consisting of half a pint to a pint of milk, with from two to 
six ounces of whole-meal bread and a similar quantity of figs or 
dates, prepared in milk as above described. Obviously this diet is 
not sufficiently sustaining to be long endured. 

Digestibility. — Among the commoner fruits of easy digestion are 
grapes, oranges, grape fruit, lemons, cooked apples, figs, peaches, 
strawberries, and raspberries. 

Somewhat less digestible are melons, prunes, raw apples, pears, 
apricots, bananas, and fresh currants. 



VEGETABLE FOODS 1 79 

Of course the digestibility depends very much upon ripeness and 
freshness of the fruit as well as personal idiosyncrasy, and any classi- 
fication can only be approximate. 

Fruits most Useful for Invalids. — The most useful fruits for the 
sick are lemons, oranges, baked apples, stewed prunes, grapes, 
banana meal (not the fruit pulp). 

Varieties of Fruits. — Lemons, limes, and shaddocks may be con- 
sidered together as possessing the same general properties. Owing 
to the potash and other salts and abundant vegetable acids which 
they contain, they are the most serviceable of the antiscorbutic fruits, 
and also afford an agreeable acid and pungent flavour to articles of 
diet which might become monotonous in taste. For many persons 
the addition of a little lemon juice to some articles of food, such as 
cooked cereals and porridge or broiled fish, renders them more im- 
mediately digestible, and it can be regarded as having almost a 
specific action in promoting gastric digestion, although it is difficult 
to say in just what manner this comes about. Lemons are therefore 
a most desirable addition to the diet kitchen. 

Lemon juice is a well-known mild remedy for seasickness, and 
holding a thin slice of freshly cut lemon in the mouth often removes 
the disagreeable taste from a coated tongue, cleanses the mouth, and 
may even counteract nausea. Sour lemonade taken in moderation, 
and made quite strong by squeezing the juice of one or two lemons 
in a small tumblerful of water, with the addition of only one or two 
lumps of sugar, is a cooling and refreshing drink in fevers, and does 
more to diminish the craving of thirst than almost any other form of 
beverage. 

For those who fancy effervescing drinks, the lemonade may be 
improved by using one of the aerated waters — such as Apollinaris, 
Vichy, or carbonic-acid water — instead of plain water, or efferves- 
cence may be produced by the addition of five or ten grains of sodi- 
um bicarbonate. In many cases this mild remedy is beneficial to the 
stomach. 

Henry claims that pure lemon juice poured into the nose will 
often control epistaxis. Fresh lemon juice has a popular reputation 
for warding off rheumatism, but it has been shown to have very little 
influence over nitrogen elimination, although it increases the phos- 
phates of the urine (K. Dauber). 

Limes. — The lime is a thin-skinned acid fruit, but there is also a 
sweet variety. Although less extensively eaten throughout this 
country than the lemon, which it resembles in effect, it is equally 
serviceable, and nearly ten thousand gallons of condensed lime juice 
are imported annually into this country from Jamaica. To make 
this juice the fresh limes are pressed by machinery, and the seeds 
and pulp are removed by straining and filtering. The juice is then 
boiled down to a high degree of concentration. It is carried on 



180 FOODS AND FOOD PREPARATIONS 






sailing vessels to prevent scurvy, and used in almshouses and pris- 
ons, where the diet is monotonous. 

The shaddock, pomelo, or Citrus pomclanus, is a very large, globular 
pulpy fruit, which may attain to a weight of fifteen pounds. The 
rind is thick and acid, and the very juicy pulp is bitter. The fruit 
keeps fresh for a long time. A smaller variety, known as the grape 
fruit, has come into general use of late, although it is still a relatively 
expensive fruit in most parts of the country. It grows in pendant 
clusters. Many persons find that half a grape fruit taken at the com- 
mencement of breakfast has both a laxative and diuretic action, and 
it is always cooling and agreeable to those who do not dislike a bitter 
taste. The objection to its use is that it requires a large quantity of 
sugar to make it really palatable and diminish its astringency. This 
is disadvantageous in cases of flatulent dyspepsia, but for invalids 
who are convalescing from prolonged fevers, suppurating disease, 
etc., an excellent tonic may be given by cutting a grape fruit in two 
and pouring half an ounce or more of good rum into the fruit, with 
the addition of a little sugar. The bitterness is entirely disguised 
and the combination is agreeable and appetising. 

Oranges. — Oranges are an exceedingly useful article of invalid 
diet. The juice of ripe oranges allays thirst, and it is well borne in 
cases where there is considerable gastric irritation and tendency to 
vomiting. It is only in the worst forms of gastric disorders that 
orange juice disagrees, and there is no fruit which is so generally 
available in the sick-room, for it is agreeable to almost every one, 
and is refreshing in fevers. I often give it in typhoid fever. 
Orange juice is laxative, particularly for infants, and is the best 
remedy for infantile scurvy. It may be given undiluted or made 
into orangeade with one of the effervescing waters. In renal and 
other diseases in which it is desirable for the patient to drink large 
quantities of fluid for its diluent and diuretic effect, the addition of 
orange juice to beverages will encourage their consumption. 

Orange marmalade is a wholesome relish, having an appetising, 
bitter flavour. 

Orange water ice, as well as lemon ice, well frozen, if not made 
too sweet, may be allowed in the milder forms of fever, inflammations 
of the throat, etc., especially in children. It is soothing, refreshing, 
and cooling, and is less likely to disagree than the richer ice cream. 

Apples, when ripe and properly selected, are extremely whole- 
some and very digestible. They contain abundant potassium and 
sodium salts, as well as those of lime, magnesium, and a trace of iron. 
Their nutritive value is not high, depending mainly upon a little 
sugar, for they are largely composed of water, having over 83.5 per 
cent (Bauer). In dried apples the percentage of water is reduced 
to one third, while that of sugar is proportionately increased. 

Apples contain free organic acids (malic and gallic) as well as 



VEGETABLE FOODS l8l 

salts, such as malates, citrates, and tartrates. They also contain lime, 
phosphates, plant albumin, gum, and chlorophyll. They are good 
antiscorbutic remedies, and are laxative, especially when taken into 
an empty stomach. There are many dyspeptics who thrive upon 
apples, even if eaten raw, and who can regulate the action of the 
bowels with them effectually. They should be given to most in- 
valids only when cooked. They are most digestible when baked and 
eaten with cream, or they may be beaten with white of egg to add 
to their nutritive power. They are both palatable and very digesti- 
ble for convalescents if stewed as apple sauce, when there is no 
objection to the addition of the greater quantity of sugar which is 
required in this method of cooking. They should be avoided in all 
cases of diarrhcea, gastro-intestinal irritation, and diabetes. 

Pears are similar to apples in their effect, but are less laxative. 
If fully ripe and soft they are even more digestible raw than apples. 
They have the advantage of keeping their flavour when well pre- 
served in sirups, but they possess no special food value, and are 
mainly used for their choice flavour, aroma, and appearance, which 
stimulate the appetite. 

Quinces are indigestible unless very thoroughly cooked. 

Peaches, nectarines, and apricots are of comparatively little nutrient 
value, but their flavour and appearance make them tempting articles 
for the table. They do not contain as much sugar as apples and 
other fruits. When thoroughly ripe they are wholesome if not 
eaten in excess. They agree well with some gouty persons, and are 
even allowed to diabetics in cases of moderate severity. Peach and 
apricot juices are laxative. 

Pineapples (Ananassa sativa), as usually obtained in this country, 
have been picked green in Cuba, and if eaten raw are indigestible. 
Their ripe juice is, however, very wholesome, and they contain a 
ferment capable of digesting proteid material, which is used to some 
extent in the preparation of predigested invalid foods, such as Mos- 
quera's beef meal. Prof. R. H. Chittenden has isolated this ferment, 
which has a rapid softening, disintegrating, and digesting effect upon 
such proteids as blood fibrin and muscle tissue. It is an acid fluid 
which acts best in a neutral medium, but, like trypsin, it also digests 
in both acid and alkaline solution. Three ounces of the juice will 
dissolve ten to fifteen grains of dried albumin in four hours. He 
also found a milk-curdling ferment in the juice. 

Tamarinds are cooling and laxative. When added to milk they 
cause curdling, and form a whey which may be used as a beverage in 
fevers when constipation is to be overcome. 

The mango is a sweet and somewhat acid fruit, with moderately 
laxative action. 

The pomegranate is a pulpy fruit, wholesome when fresh, but it is 
expensive and little used in this country. It has a thick, tough rind, 



1 82 FOODS AND FOOD PREPARATIONS 

which is astringent, with a bitter-sweetish taste. A tseniacide for 
the tapeworm is made from an infusion of the rind, but it is so 
nauseous and disgusting to the taste that patients can seldom retain 
it unless it is put into the stomach with a tube. 

Bananas. — The banana is really a variety of the plantain, or Plan- 
tago musa, but the fruit is not so large or so hard as that commonly 
called plantain, and the flavour is far more delicate. The botanical 
name of the banana, Musa sapientum, was given because it constituted 
the principal food of the Brahmin caste of India. There are many 
score of varieties of the banana, ranging from the most delicate 
examples of the Musa sapientum family to the heaviest of the plan- 
tains, and they vary in digestibility as they do in flavour. Casati 
(Equatorial Province, 1891) names some fourteen varieties, having 
different characteristics and existing in the Equatorial Province of 
Africa alone. He noted that, curiously, only the women and chil- 
dren ate the natural fruit, the warriors feeding on the fruits dried and 
prepared in oil — probably from an intuition that they were more 
highly nourished by the concentrated food. 

In the West Indies, in the islands of the Pacific, along the Congo, 
and throughout Central Africa many natives eat bananas as their 
staple article of food, and maintain good physical development. The 
fact that a diet consisting solely of this fruit will sustain life for long 
periods is owing to the relatively high percentage of nitrogen which 
it contains compared with sago, arrowroot, and similar carbohy- 
drates. This percentage amounts to nearly five parts per hundred 
of the entire fruit, or one fifth of the total solids (Corenwinder). 

Grown on a given acreage, bananas will support a larger number 
of persons than wheat. 

The banana has of late years assumed a very -important position 
among fruits sold in this country. Improvements in cultivation and 
means of transportation, and the length of time through which the 
fruit will keep without spoiling, are accountable for this, and up- 
wards of one hundred thousand bunches of bananas are sold per 
month for distribution" in New York city and vicinity alone. It 
ranks equally with the orange in extent of consumption, and during 
the winter months it is often the only fresh fruit which is universally 
obtainable in remote country districts, while its cheapness places it 
within the reach of almost every one. 

In British Guiana the banana is employed especially as a nourish- 
ing food for young children and invalids. 

Many persons find that they cannot easily digest bananas as we 
obtain them in this country ; but this no doubt depends upon the fact 
that the fruit shipped to the United States is picked very green, and 
is often quite immature and irregularly ripened when eaten. Imper- 
fectly ripened bananas are composed chiefly of starch, but, as the 
natural ripening proceeds, the saccharine material is converted 



VEGETABLE FOODS I 83 

into a mucilaginous substance, which in turn forms dextrin and 
glucose. 

The flour, which is made by drying carefully selected and well- 
ripened bananas, is, however, remarkably easy to digest, and highly 
nutritious. 

Surgeon Parke ("My Personal Experience in Equatorial Africa," 
(p. 416), in an instructive and interesting account of his experience 
with the sick of the Emin Pasha Relief Expedition, refers to Mr. 
Stanley, who was in the midst of a severe attack of acute gastritis, 
as follows : " He eats porridge made with banana flour and milk. It 
is very light and digestible, and has more flavour than arrowroot ; it 
is also very nutritious. We whites have very good reason to know 
this fact now, as we have mostly lived on banana flour for the past 
two years." 

During most of this period, it should be observed, the members 
of the expedition were taking very long marches and were suffering 
from frequent attacks of malarial fever, which were a severe test of 
the nutritive qualities of any dietary. 

Farinaceous food is so prone to undergo malfermentation in the 
stomach when the normal digestion is disordered that it becomes 
very important to seek some variety of starchy food which can be 
easily assimilated without the production of" acid eructations, flatu- 
lence, or heartburn. The starchy foods which have heretofore been 
obtainable in this country for this purpose have been all derived 
from tubers or cereals which have been rendered more assimilable by 
predigestion or " malting." 

It is difficult to make a good fruit flour, for many fruits, when 
dried, form a mucilaginous mass like the fig, or a sticky material like 
the raisin, or shrivel to a stringy substance like the apple and the 
apricot. But the banana, in some varieties and conditions, consti- 
tutes an important exception, and when carefully selected and thor- 
oughly dried it can be ground into a meal or even into a flour, mak- 
ing as fine a powder as arrowroot, having a white or pale greyish or 
yellowish colour, and an agreeable faintly aromatic odour and taste. 

This meal possesses decided intrinsic advantages as an invalid 
food. I have tested these preparations, both experimentally in the 
laboratory and clinically, and found that an unboiled, saturated 
aqueous solution of banana flour contains a very large percentage of 
sugar — from one half to three fourths as much as certain of the best 
known prepared saccharine foods for infants to which sugar had 
been artificially added. The finest banana flour, called " bananose," 
at the end of one and a half hour of pancreatic digestion was capa- 
ble of developing twice as much sugar as the same quantity of oat- 
meal or farina, and approximately one and a half time as much sugar 
as cornstarch. Saliva, when substituted for pancreatic extract, pro- 
duces a similar effect. 
14 



1 84 FOODS AND FOOD PREPARATIONS 

The banana flour, when prepared from the best quality of bananas,, 
is made into a thin gruel or porridge by the addition of either water 
or milk, and eaten with cream it constitutes a delicious and highly 
nutritious article of diet suitable in cases of gastric irritability and 
acute gastritis, etc. It is particularly serviceable for children be- 
tween five and ten years of age. For those craving an acid flavour, 
lemon juice with powdered sugar upon the banana porridge is found 
to be very acceptable. The records of some fifty patients in the New 
York and Presbyterian Hospitals to whom I gave gruel or porridge 
made with banana flour show that it was exceptionally well borne by 
irritable stomachs, almost never vomited, having no tendency to pro- 
duce acidity from flatulence, nor did it cause diarrhoea or any ap- 
parent laxative effect. It proved very useful in several cases of sim- 
ple gastritis and acute gastritis complicating chronic indigestion and 
in the early convalescent stage of typhoid fever. It was used with 
advantage even during the fever itself whenever a change from an 
exclusive milk diet seemed indicated either by the patient's dislike 
for milk or by its causing dyspepsia. 

The taste of banana flour is peculiar, and is not always agreeable 
at first ; but it may be so modified by different processes of cooking 
that the majority of patients find it much more palatable than the 
conventional arrowroot, cornstarch, or farina. It is a decided gain 
to be able to enlarge the list of starchy foods adapted to feeble 
digestions by a fruit flour which presents the following advantages : 
An agreeable variety of taste ; a high percentage of nitrogen, dex- 
trin, and glucose ; ready digestibility ; high nutritive value ; the prop- 
erty of keeping definitely in a concentrated dry state, ready for im- 
mediate use. 

Grapes. — Grapes are universally grown and enjoyed on account 
of their delicious flavour and aroma as well as their general whole- 
someness, and they constitute an important article of diet. Per- 
fectly ripe and seedless grapes, such as the Black Hamburg and 
other varieties, have long been recognised as an excellent food for 
invalids. Grapes contain so large a proportion of water that they 
possess but little nutrient property, although they hold considerable 
sugar, but the salts which they furnish to the system are useful. 
These salts are the sulphates, phosphates, and chlorides of sodium, 
potassium, calcium, magnesium, and iron. 

The habit which some people have of swallowing the pulp whole 
with the seeds, however small the latter may be, cannot be too 
strongly condemned. The seeds under no circumstances are di- 
gested, being too hard and tough to be affected by any of the juices 
of the digestive tract, and they therefore act as irritants or foreign 
bodies. It was originally believed that inflammation of the appendix 
vermiformis was often caused by the entrance of one or two sharp- 
pointed grape seeds into this small division of the alimentary canal, 



VEGETABLE FOODS I 85 

but this has been proved to be an exceedingly rare occurrence. The 
main disadvantage of swallowing seeds consists in their interference 
with normal digestive processes, while they are liable at any time to 
cause more serious disturbance of the nature of diarrhcea, enteritis, 
or intestinal obstruction. Swallowing the skins of grapes is equally 
harmful. 

Grapes, on account of their sugar, must be excluded in cases of 
diabetes and gout. A special " grape cure " has been established for 
some diseases. It is discussed under that heading. Unfermented 
California grape juice constitutes an agreeable, wholesome, and 
slightly laxative, non-alcoholic beverage, which may be prescribed 
during mild fevers and in convalescence. Prof. Albert R. Leeds has 
recently sent me the analysis of a new grape food which he says li is 
entirely different from the grape juice, inasmuch as it contains, both 
in amount and condition, the constituents of the grape to a point of 
practical completeness which the manufactured juices have failed to 
attain. I have verified by most exhaustive tests the absence of all 
germs of fermentation, and this sirup will certainly keep indefinitely, 
even in the absence of alcohol or antiseptic." This " liquid grape 
food " contains protein and 64 per cent of grape sugar, with no alco- 
hol and no starch. 

Raisins, prepared by sun-drying from certain species of grapes 
which are particularly rich in sugar, form a useful food, chiefly on 
account of the agreeable flavour which they impart to more insipid 
substances. (See also Raisin Wine.) 

Raisins are usually made from white grapes, but they turn dark 
purple or brown from oxidation of the tannic acid of their skins 
(Leoser). Muscatel raisins are dried on the vine by incising the 
stems to cause withering of the grapes. 

Raisins cannot be eaten very abundantly without disordering 
digestion unless they have been cooked. Added to some forms of 
farinaceous food — such as rice pudding, sweetened breads, buns, 
cakes, pemmican, and the like — they increase the appetite. If given 
to children, as they too often are, they should be stoned carefully 
beforehand, and the tough skins must not be swallowed. The latter 
contain a whitish waxy material which keeps the grapes waterproof. 

Plums. — Plums and greengages are wholesome fruits when they 
are wholly ripe ; but they remain fresh for only a short time, and are 
often on that account picked and sent to market in an unripe condi- 
tion, in which they are very indigestible, and are prone to excite 
diarrhcea and intestinal colic. 

Prunes. — Prunes or dried plums are obtainable in various forms 
and sold in large masses like dates, or preserved individually in jars, 
in which form they have the advantage of keeping well for a long 
period. They contain a large percentage of sugar. They have a dis- 
tinctly laxative effect, eaten raw or, preferably, stewed, and they are 



86 



FOODS AND FOOD PREPARATIONS 



very wholesome and useful in cases of chronic constipation. They 
are comparatively inexpensive, and by some patients may be taken 
two or three times a day. They have a good effect in regulating the 
bowels in children, and three or four prunes given once or twice a 
day between meals will sometimes prove quite sufficient for this 
purpose. 

Pranelles are sold in masses dried like dates. They have a pleas- 
ant acid flavour, but are not very digestible. 

Olives are eaten for their agreeable flavour and their nutrient 
value, which is due to the oil they contain. (See Olive Oil.) They 
are much eaten as a relish, either plain or stuffed with peppers, and 
are used for garnishing salads, sauces, etc. About seventy varieties 
are now grown in California. They may be eaten fresh with bread 
in the warm countries where they grow, but they are too bitter for 
most palates, and are usually preserved by soaking respectively in 
(a) strong lye, (b) fresh water, and (c) salt solution, and are left in 
the latter for preservation. The lye neutralises their bitter taste. 
In Greece dried olives are much eaten. The composition of the ash 
of California olives presents, among other ingredients, 60 per cent of 
potash, 16 per cent of lime, and 8.3 per cent of phosphoric acid. 

Composition of Pickled Ripe and Green Olives 
(C. B. Smith and F. Langworthy) 





Water. 


Fats (oil). 


Carbohy- 
drates. 


Protein, 
ash, etc. 


Pickled ripe olives 


Per cent. 
65.08 
78.41 


Per cent. 
25.52- 
12.90 


Per cent. 

3-75 

1.78 


Per cent. 
5.65 
6.9I 


Pickled green olives. 



Berries. — The strawberry, on account of its exceptionally agree- 
able flavour, and also from the fact that it is one of the first fruits of 
the spring season in the eastern part of this country, is enjoyed by 
almost very one. There are, however, a few persons who have a 
striking idiosyncrasy against it, and in whom urticaria or more or 
less violent gastro-enteritis with sore throat (Osier) is promptly 
developed by taking even a few berries. The reason for this is not 
fully explained, for analysis of the strawberry fails to show any 
product which is peculiar to itself. There must consequently be 
some combination of organic acids or other materials existing in 
this berry which is exceptionally irritating to some persons. 

The strawberry is usually a very wholesome food. It contains 
abundant salts of potash, lime, and soda, which give it a moderate 
diuretic action ; it is also slightly laxative, partly from the seeds 
which it contains. There are many modes of eating, cooking, and 
preserving the strawberry which are too familiar to require comment 
here. Some persons learn that eating the berry with pepper or lemon 



VEGETABLE FOODS 187 

juice enables them to digest it better, and those who suffer from 
flatulent dyspepsia, if they can digest the berry at all, do well to take 
it without sugar. 

Currants, bilberries, mulberries, blueberries, huckleberries, rasp- 
berries, blackberries, and gooseberries all contain considerable free acid, 
and are moderately laxative, partly on account of their seeds, but 
their expressed juices sometimes have the same effect. Not all ber- 
ries are laxative, however. Huckleberries and blueberries may be 
laxative when eaten with their seeds and skins, but Winternitz has 
recently shown that a decoction made from these berries is a good 
astringent for use in chronic diarrhoea. Blackberries have a similar 
action. 

The expressed juice of red currants, raspberries, or blackberries 
makes a cooling and refreshing beverage or " shrub " when added to 
some effervescing water, such as Apollinaris or carbonic-acid water, 
and may sometimes be used in fevers, although lemon juice is usually 
preferable. 

Currants are preserved in various ways, the chief one being in 
the form of jelly. Prepared in this manner, they constitute an appe- 
tising and wholesome flavouring material, which may be taken with 
meats and other foods to excite the appetite of invalids and con- 
valescents whose chief difficulty is lack of desire for sufficient food. 

Currants, raspberries, blackberries, etc., are frequently made into 
jams. These, on account of the large quantity of sugar which is 
added in their preparation, are quite nutritious, and their numerous 
seeds have a laxative action. For this purpose they are sometimes 
beneficially given to children to be eaten with bread and butter. 
They aid in satisfying the natural craving of children for sweets, 
and, if taken in moderation, they are very wholesome, and their 
flavour may encourage the eating of more nutritious but less agree- 
ably flavoured food, such as rice, cornstarch, or farina. 

The gooseberry is much more popular in England than in the 
United States. It contains citric and malic acids as well as sugar. 
It is rendered more wholesome by cooking, and is sometimes made 
into wine. 

The elderberry furnishes an astringent wine, which is also some- 
what diuretic and sudorific. 

Melons. — Melons are of little service for nutrition, but they are 
so agreeable to the palate that they are in very general use. The 
varieties commonly obtainable in this country are the cantaloupe, or 
muskmelon, and watermelon, and of these, the former is less likely to 
produce gastro-intestinal disorder when not eaten too freely. 

These fruits contain so large a proportion of water — upward of 
95 per cent — that they are not satisfying to the appetite ; and since 
in hot weather they are cool and refreshing, overindulgence in them 
is a common fault, and most of the ill repute of watermelons has 



1 88 FOODS AND FOOD PREPARATIONS 

arisen in this way rather than from any specific injurious effect which 
they produce. If eaten with other food, they dilute the gastric 
juice. Well-ripened muskmelons may often be eaten by invalids in 
moderation to promote the appetite, served at the commencement of 
a meal, at which time it is best that most fruit should be eaten when 
taken with other food. 

Citrons are very indigestible. 

Figs and Dates. — Figs and dates are chiefly eaten in the United 
States in the dry form, although m California and elsewhere they 
may be obtained fresh. These fruits hold large quantities of sugar, 
especially in their dry state, in which this ingredient is not only con- 
centrated, but changed in the drying process. They also contain a 
little nitrogenous material, so that they have more nutritive value 
than many fruits ; in fact, in some Eastern countries they consti- 
tute a staple article of diet, as illustrated by the use of the date in 
Arabia. 

Figs have a decided aperient action, which is chiefly, but not 
solely, owing to their seeds. Three or four dried figs taken with a 
glassful of water at night before retiring, and again half an hour be- 
fore breakfast, will sometimes cure mild constipation. The dried 
figs, like prunes, may be stewed if preferred. They contain a large 
percentage of glucose. The best figs, called Turkey figs, are raised 
in Smyrna, and when dried will keep for a long time. 

Fungi 

There are many species of fungi, some of which are available for 
food, while others are irritating, and still others produce violent 
gastro-intestinal disorder, and by their absorption give rise to symp- 
toms of collapse, and may cause death. 

Konig gives the following percentage composition : 



Water 

Non-nitrogenous substances 

Fat 

Grape sugar, mannite 

Other non-nitrogenous substances, 

Woody fibre 

Ash 



Fresh mushroom. 


91 


. 11 


2 


•57 


O 


13 


I 


05 


3 


71 





67 





76 



Fresh truffle. 



72.08 
8.9I 
O.62 

7-54 
7.92 
2.21 



Fresh common 
morel. 



9O.OO 
3-48 
O.24 
O.72 

3-95 
0.67 
0.94 



Mushrooms. — Mushrooms, on account of their nitrogenous mat- 
ter, are of some slight use as food ; but if eaten in sufficient quantity 
to yield much nutriment, they always disagree. Bauer says : " Judg- 
ing from their chemical composition, they ought to have no small 



VEGETABLE FOODS 1 89 

value as foods, but it is doubtful how far they are really utilised in 
the alimentary canal." 

Mushrooms have a tempting flavour, which is developed on cook- 
ing, and while they agree with most persons in health and form an 
acceptable article of diet, there are some persons who can never 
eat even the simplest varieties without suffering more or less from 
acute gastro-intestinal irritation. They should never be eaten raw. 
They are usually served alone, broiled upon toast or as a dressing 
for beef, fillet, steak, etc., or they may be preserved in olive oil or 
by drying. Their digestion requires fully three hours. The com- 
mon mushroom consists of 91 per cent water, besides 3J per cent 
of carbohydrates, and 4 per cent of proteid, with salts and other sub- 
stances. 

Truffles. — The truffle is a subterranean vegetable of the order of 
Thecaphore. It is an expensive luxury, and is used to add flavour in 
cooking and as an ingredient of rich meat sauces, pates, etc. It con- 
tains no sugar. Eaten in quantity by itself it is a highly indigestible 
substance. It easily decomposes with a very offensive nauseous 
odour. There are several varieties, of which the black is the chief, 
and it is obtained from beneath the trees of oak forests of Perigord 
in Southern France, where it is hunted by trained Spanish poodles or 
sows, whose sense of smell enables them to detect the fungus beneath 
the ground. There is a special hereditary race of trufrling swine, 
broken for the purpose. 

The morel is a friable, greyish-black, cone-shaped mushroom, 
which grows extensively in a variety of dry soils, but, like the cepe, is 
obtained principally in France. It may be cultivated artificially. It 
is used for flavouring, like the trufBe. 

Cepe is a name given to several mushrooms belonging to the 
Boletus family, which are globular in shape, and coloured orange or 
white. 

Poisonous Fungi. — Most poisonous fungi are distinguished from 
the non-poisonous by a warty cap. They are often viscid and have 
other peculiarities of structure, colour, etc. They are acrid or 
astringent, and have a pungent, disagreeable odour (Christison). 
Poisonous mushrooms may either produce violent gastro-intestinal 
symptoms, which are seldom fatal, owing to the prompt evacua- 
tion of the poison from the system, or these symptoms are fol- 
lowed by a condition of narcosis ending in fatal collapse. The 
pupils are contracted, the urine is suppressed, the face is livid, 
and there is general vasomotor paralysis. The conjunctivae are 
congested. 

Muscarin is a substance isolated from poisonous fungi, which is a 
violent cardiac poison and constrictor of the pulmonary blood ves- 
sels, producing dyspnoea, prostration, and death. Its effects are 
antagonised by belladonna. 



i90 foods and food preparations 

Lichen 

Iceland moss is used extensively as a food by dwellers in the 
arctic regions. 

Konig gives the percentage composition of the dried moss as fol- 
lows : Water, 15.96; nitrogenous matter, 2.19; fat, 1.41 ; non-nitro- 
genous matter, 76.12. 

A bread is made from it after carefully washing out two bitter 
organic acids which it contains. Senator has recommended this 
bread for use by diabetics. 

Nuts 

Nuts contain protein, with some starch and more or less fat, and 
very little water. From 50 to 65 per cent of the common nuts is shell. 
With the exception of the cocoanut, chestnut, almond, and English 
walnut, the varieties eaten in this country furnish but little nutri- 
ment. Their chief value is to stimulate the appetite and afford 
variety in the diet. Excepting chestnuts and cocoanuts, they are 
usually eaten raw, as dessert, but they are much used in confectionery. 
A few nuts are used in salads and as dressing for fowl. As a rule, 
they are to be proscribed from invalid dietaries, but, with the excep- 
tion of chestnuts and peanuts, they may be allowed to diabetics. A 
preparation of malted nuts which may be obtained in market is both 
nutritious and digestible. It contains emulsified nut fat, maltose, and 
vegetable protein. 

Almonds contain a ferment called emulsin and much fat, and sweet 
almonds have 3 to 5 per cent of sugar, but no starch (Bauer). This 
low percentage of sugar makes them of service in the treatment 
of diabetes, in which disease they are sometimes used as a sub- 
stitute for bread after being ground into meal. (See Diabetic 
Breads.) 

Macaroons are a digestible form of cake for convalescents and 
children composed chiefly of almonds and sugar. 

Almonds are wholesome and nutritious. They should not be 
eaten in cases of gastric irritability, but occasionally dyspeptics 
in whom gastric digestion is slow derive benefit from eating a 
few salted almonds with meals. They should be soaked and 
peeled or " blanched," otherwise their skins may set up gastric 
irritation. 

The bitter almond contains hydrocyanic acid, sugar, and oil, and 
is not used except for flavouring cough mixtures. Almonds are 
imported chiefly from Italy, France, and Spain, but of recent years 
they have been extensively grown in California. 

English walnuts eaten liberally between meals may assist in over- 
coming constipation through the bulk of insoluble residue which 
they leave, and possibly also from the oil which they contain. 



VEGETABLE FOODS 



191 



Cocoanuts are very indigestible even when thoroughly desiccated 
and grated. The cocoanut contains a proteolytic ferment which con- 
verts meat into albumoses with considerable activity. The cocoa- 
nut has been successfully grown in Florida. 

Brazil nuts, pecan nuts, beechnuts, butternuts, filberts, etc., all hold 
much oil, and are difficult of digestion. Butternuts easily become 
rancid after being shelled. 

Chestnuts contain 15 per cent of sugar with so much starch that 
they are very nutritious, and in some parts of Italy they are made 
into cakes and eaten by the peasants as a substitute for potatoes. 
Raw chestnuts are wholly indigestible, but if thoroughly roasted or, 
better still, if long boiled, they become much less so. They should, 
however, not be given to invalids. 

The pistachio, a native nut of Syria, has a greenish, almond-like 
kernel. It is chiefly used in confectionery and ices for both its colour 
and delicate flavour. 

Peanuts are described under Legumes, p. 165. 



Composition of Nuts and some Other Food Materials (C. F. Langworthy) 



Almonds 

Brazil nuts 

Filberts 

Hickory nuts 

Pecan nuts .... 

English walnuts 

Chestnuts, fresh 

Chestnuts, dried 

Acorns . 

Beechnuts 

Butternuts 

Walnuts 

Cocoanuts 

Cocoanuts, shredded 

Pistachios, kernels 

Pine nuts or pinons (Pimis 

edulis) 

Peanuts, raw 

Peanuts, roasted 

Litchi nuts 

Beefsteak 

Wheat flour 

Potatoes 



Refuse. 



Per ct. 
64.8 
49.6 
52.1 
62.2 
53-2 
58.0 
16.O 
24.O 

35-6 
40.8 
86.4 
74.1 

4S.8 



40.6 

24-5 
32.6 
41.6 

12 8 



20.0 



Edible 
portion 



Per ct. 
35-2 
50.4 

47-9 

37.8 

46.8 

42.0 

84.0 
76.0 

64.4 

59' 
13 

25' 

51. 

roo. 
100. 



59-4 
75 5 
67.4 
58-4 
87.2 
100. o 
80.0 



COMPOSITION AND FUEL VALUE OF THE EDIBLE PORTION 



Water. 



Per ct. 

4.8 
5-3 

3-7 
3-7 
3.o 
2.8 
45-o 
5-9 
4 
4 
4 
2 

14 

3 



4-2 



•4 
.2 
.6 
9 
■9 
12.8 

78.3 



17 
61, 



Protein. 



Per ct. 
21 .O 
17.O 
15.6 

15-4 



21 

27 

27.6 
5-7 
6-3 

22.6 

14.6 
25.8 
30.5 

2-9 
18.9 
10.8 

2.2 



Fats. 



Per ct. 
54-9 

66.8 

65 3 
67.4 
71.2 
64.4 
5-4 
7.0 
37-4 
57-4 
61.2 

56.3 
50.6 

57-3 
54-5 



61 

38. 
49 



Car- 
bohy- 
drates. 



Per ct. 

17-3 

7.o 
13.0 
11. 4 

13-3 
14.8 
42.1 
74.2 
48.0 
13.2 
3-4 
11. 7 
27.9 
31.6 
15.6 

17-3 
24.4 
16.2 

77-5 

74.8 
18.4 



Ash. 



Per ct. 



3-1 

2.8 

2.0 

2.5 

1-5 

1.0 

. 5 
1.0 



Fuel 

value 

per 

pound. 

Cat. 

3,030 

3>329 

3,432 

3,495 

3,633 

3,305 

1,125 

1,875 
2,718 
3,263 

3,37i 
3,105 
2,986 
3,125 
3,oio 

3,364 
2,560 

3,177 
1.453 
1,130 
1,640 

385 



,f The meat of nuts, excepting chestnuts and cocoanuts, contains 
nearly 50 times as much fat and less than one fifth as much carbo- 
hydrates as wheat flour, and has about double the fuel value — i. e., 
energy-producing power. A pound of unshelled nuts will furnish 



I92 FOODS AND FOOD PREPARATIONS 

about half as much protein and the same amount of energy as a 
pound of flour. Owing to their high fuel value and low protein con- 
tents, nuts would not make a well-balanced food when eaten by 
themselves " (C. F. Langworthy). 

V. FATS AND OILS 

Fats and oils contain but three elements — namely, carbon, oxy- 
gen, and hydrogen. In the starches and sugars the proportion of 
oxygen and hydrogen is such as to form water, H 2 0, when their 
molecules are split up ; but in the group of fats oxygen is not present 
in sufficient quantity to form water with all the hydrogen atoms, and 
in their combustion with oxygen considerable heat is evolved. In 
some fats, like butter, very little oxygen is present, and carbon and 
hydrogen compose the bulk of the substance. The amount of fat 
which from time to time is stored in the body is regulated to a greater 
degree than any other substance by muscular exercise, which, if ac- 
tive, always tends to prevent its accumulation. The storage of fat is 
favoured by sleep as well as inactivity. (See Obesity and Leanness.) 

About one fifth of the entire body weight is composed of fat, 
but only about a quarter of an ounce is contained in the blood. 
Before death results from starvation 90 per cent of the body fat is 
consumed. The chief sources of this fat in the human body are 
undoubtedly starches and sugars, but it is probable that under cer- 
tain conditions it may also be derived from fatty food. 

Fat is required to promote the earlier stages of growth and de- 
velopment of the organism, and there are also, many forms of disease 
and degenerative changes which are accompanied by increased accu- 
mulation or production of fat in and between the tissues and cells. 
It is impossible to live in perfect health without fatty food, and it is 
equally impossible to live long upon fat alone, for it soon disorders 
the digestion and causes absolute disgust. 

Fat constitutes one of the ingredients of pus, and is found in the 
normal living white blood-corpuscles, and after the ingestion of fat 
in excess as food, a sufficient quantity of it may be absorbed into 
the serum of the blood to give rise to a thin film upon its surface 
when shed. 

In hot climates where fat meats are scarce, or their use is pro- 
hibited by the religion of the inhabitants, they employ the oils of 
fish, vegetables, or fruits instead. 

Uses of Fats. — The chief uses of fatty food are : 

1. To furnish energy for the development of heat. 

2. To supply force. 

3. To serve as covering and protection in the body. 

4. To make more plastic various structures of the body and give 
rotundity to the form. 



IM.ATK IX 




Beef Fat x 40. 




ANIMAL FATS, WfAGNIFIED. 



{From liiillctin No. 13, Division of Chemistry, United? States Agricultural Bureau). 



FATS AND OILS 1 93 

5. To spare the tissues from disintegration, for, although their 
combustion in the body results largely in the production of heat, they 
also take part to some extent in tissue formation. 

6. To serve for storage of energy. 

The various forms of energy manifested in the different nitro- 
genous tissues — as muscular action, secretion, nerve force, etc. — are 
more or less intimately dependent upon fat combustion. It was 
originally believed that the force of the body was supplied by the 
oxidation of nitrogenous materials. Fat eaten with the food was 
supposed to be deposited again as fat in the tissues of the body 
without material change, but of recent years this theory has been 
very largely recast, and the primary value of fatty food consists un- 
doubtedly in its contribution to force production and its power of 
saving other tissues, especially the albuminous, from destruction by 
oxidation, whereas its secondary use is in connection with tissue 
formation. Fats do, however, enter into the composition of many 
different tissues, even those of the nervous system. 

The fats and oils which are employed as food all serve essen- 
tially the same purpose, and may therefore be grouped together as 
a distinct class. There is a general resemblance in their physical 
properties, although they differ considerably in the melting point. 
The several food fats and oils are of various chemical composition, 
but after being absorbed they are recognised mainly in one or two 
simple forms, chiefly as stearin and olein. 

The use of animal oils, such as lanolin, and of the petroleum 
products, like purified vaseline, has very largely superseded the ex- 
ternal application of other fatty substances — lard, etc. — to the skin 
for the purpose of lubrication. 

It is not possible to get very much nourishment into the body 
by osmosis through the integument, but some improvement seems to 
follow the rubbing of fats and oils, such as cacao butter, olive oil, or 
cod-liver oil through the skin of marasmic children and other pa- 
tients. (See Marasmus.) One or two teaspoonfuls of the oil may be 
rubbed in twice a day on the thighs, abdomen, and chest. The state- 
ment that the application of fats to the surface of the body by 
inunction reduces the body temperature is not substantiated by 
experience. 

The treatment of biliary calculi by the administration of large 
doses of olive oil — two or three ounces at a time — given upon an 
empty stomach, has been suggested, apparently with the idea that it 
might have some local lubricating action. Cases have been reported 
in which gallstones have been said to appear in the feces as a result 
of this treatment, but it has been shown that the oil itself may 
become mixed with inspissated intestinal mucus and form small, 
hardened masses, which have been mistaken for gallstones. There 
is no foundation for the belief that oil is of anv value for cholelithia- 



194 FOODS AND FOOD PREPARATIONS 

sis, nor is it possible that it should enter the bile ducts to " lubricate '? 
them. 

Fats and oils are useful preservatives of many foods by prevent- 
ing access of air, drying, and decomposition. A layer of oil floating 
on top of a flask of wine is capable of preserving its delicacy of 
flavour for a long time (Chambers). Oil preserves fish, like sardines, 
and layers of lard are used to protect jars of potted meats, pdte-de- 
fois-gras, etc. Oils and butter protect eggs from decomposition. 

Digestibility of Fats. — There is some difference of opinion as 
to what extent fat may aid or retard the process of digestion, but 
it is a matter of very common experience that those persons whose 
digestive organs are feeble do not tolerate fats or oils well when 
eaten with other forms of food. This is no doubt owing to the fact 
that fats are practically unaltered in the mouth and stomach, and 
in the latter, when melted, they coat the mucous membrane and 
surround the particles of food with a thin film which materially 
interferes with the normal action of the gastric juice. For this 
reason fats are to be avoided by dyspeptics, and the fats selected for 
special nutritive processes should be in the form of good butter, 
cream, or cod-liver oil. On the other hand, fats may sometimes aid 
the digestibility of starchy foods by preventing them from forming 
lumpy masses in the mouth and stomach. For example, a well- 
roasted mealy potato may be made all the more digestible for an 
invalid by being mashed with a little butter or cream. The diges- 
tibility of fats may be much enhanced by the process of emulsification 
— i. e., of securing an extremely fine subdivision of the oil globules. 
More than fifty years ago Horace Dobell, of London, emulsified 
beef fat and lard by means of pancreatic juice, and recently John F. 
Russell, of New York, has modified and extended the principle so 
as to emulsify all fats, fluid or solid, deriving products of permanent 
fine emulsion, capable of dilution with hot water, and possessing high 
nutritive value. These emulsions consist of one half fat, which is 
predigested and easily assimilated. 

It is stated by Ringer that fats taken fasting lessen the secretion 
of bile, whereas if taken with or after food they increase it, but, as 
many kinds of food promote the secretion independently of fat, it 
is doubtful whether the latter possesses any very decided action in 
relation to bile formation. 

Most of the fat used as food melts at the temperature of the body, 
which facilitates its digestion. 

Children often eat butter more readily than any other form 
of fat. 

As a rule, the stomach is less disturbed by animal than by vege- 
table fats taken in excess, and the former may be tolerated for a 
longer time. The limit of digestibility of increasing quantities of 
food is much sooner reached with fats than with other articles of 



FATS AND OILS I95 

diet, and they produce satiety early in a meal, but, as in the case of 
many foods, toleration may be acquired for the ingestion of fat, 
which is exemplified in the fact that many persons who cannot digest 
cod-liver oil completely at first may do so after two or three weeks' 
trial. This is, in part, due also to the general improvement in health 
which follows in some cases the administration of easily digested 
fat. Overdoses of fat at any time are apt to give rise to the forma- 
tion of irritating acids which cause nausea and vomiting, with pos- 
sibly abdominal cramps and loose evacuations. Fat taken too liber- 
ally with other food ceases to be economical for the system and 
becomes positively harmful. 

Since fat is exclusively digested in the small intestine, diseases of 
any part of the alimentary canal are contraindications for its use. 

Liquefied fats and oils are usually administered as a matter of 
routine when corrosive poisons have been swallowed, with the idea 
that they coat over the mucous membrane of the stomach and 
oesophagus and protect them from the action of the irritant. This 
protective action is overestimated, for it is difficult to coat to a 
sufficient degree a mucous membrane which is already moistened 
with watery mucus. 

The digestibility of all fat depends somewhat upon its cooked 
state. Many persons are nauseated or made dyspeptic by eating 
hot mutton fat who can eat the same with impunity when it is cold. 
In the latter condition it becomes more friable, and, if thoroughly 
mixed in chewing with starchy food, or used as suet in the form of a 
farinaceous pudding, it becomes very much more digestible. Chil- 
dren usually dislike fat meat, but they are quite willing to take suet 
puddings, which, if light and well cooked, are wholesome. 

While the various fats and oils, in general, have the same bene- 
ficial effect upon nutrition, there is considerable difference in their 
force value and in the facility with which one variety or another may 
be assimilated in individual cases. The animal fats have a higher 
nutritive power than those derived from vegetables, and liver fat, 
butter and cream, are the most serviceable of all. 

Animal Fats 

The principal animal fats and fatty foods are butter, cream, suet, 
lard, oleomargarine, the fat of beef, mutton, pork and bacon, bone 
marrow, pemmican, fish, and cod-liver oil. Oil is also made from 
the yolk of eggs. 

Butter and cream have been discussed under the heading Milk 
Derivatives (pp. 93-97). 

Lard is hog fat separated by melting from the areolar connective 
tissue. Considerably over half a billion pounds are annually pro- 
duced in the United States. Crude lard contains glycerides of oleic. 



I96 FOODS AND FOOD PREPARATIONS 

stearic, and palmitic acids, besides a little gelatin and other sub- 
stances. 

" Cuisine " is a preparation of cotton-seed oil designed to replace 
lard and cheap cooking butter. 

" Cottolene " is another substitute for cooking purposes. 

Stearins are the solid residue of animal fats remaining after pres- 
sure has separated the fluid fats. They are used in making com- 
pound lard, butterine, and similaB foods. 

Suet is the fat which surrounds the kidneys of the ox, sheep, and 
other animals. 

Oleomargarine. — Oleomargarine was invented in 1870 by a 
French chemist, Mege-Mourier, who discovered that beef fat from 
particular portions of the bullock would melt at the same tempera- 
ture with butter, and would keep longer without becoming rancid. 
The fresh fat is mashed in a grinding machine to free it from mem- 
brane. " The fragments fall into a tank heated with steam, which for 
every thousand parts of fat contains three hundred parts of water and 
one part of carbonate of potash and two stomachs of sheep or pigs. 
The temperature of the mixture is raised to 45 C." (Clark). After 
two hours the fat is withdrawn from the membranes, which have been 
digested away, and is heated still more with the addition of 2 per 
cent of salt. It is then cooled, pressed, and packed for market. 

Much discussion has arisen in regard to the wholesomeness of 
oleomargarine, and its sale has been regulated by act of Congress 
since 1886 and by many State laws. It has been declared perfectly 
innocuous, and the object of the legal control of its sale is mainly 
intended to prevent it from being fraudulently offered as butter. It 
certainly tastes better than poor butter. 

Butterine, which has now largely replaced oleomargarine in this 
country, is made in a similar manner, but with a somewhat different 
proportion of ingredients, and some of the leaf fat of the hog is added 
during the manufacture. 

Beef Fat, Pork, etc. — Beef, mutton, and pork fat consist prin- 
cipally of the glycerides of such common fatty acids as stearic, pal- 
mitic, and oleic. 

The fat of good roast beef is nutritious, and a very digestible 
variety of fat is good bacon thinly sliced and thoroughly cooked. 
This form of fat is crisp and dry, and it is often digested by invalids 
w 7 ho cannot tolerate other kinds. Ham fat and pork fat, on the other 
hand, are usually very indigestible — the more so when hot. 

Bone Marrow. — Bone marrow is an easily digestible and whole- 
some fat which has long been used as a food. The long bones of 
the ox are cut crosswise in pieces about two inches in length and 
cooked with the marrow within them. Red marrow is a useful food 
in cases of tuberculosis, secondary and pernicious anaemia, and chlo- 
rosis. But it is doubtful whether the marrow acts otherwise than 



FATS AND OILS I97 

in furnishing an assimilable fat to patients who are much in need 
of such food, and also a very digestible form of iron, which exists 
in it in considerable quantity. The marrow of young animals, such 
as the calf or lamb, is preferred for this purpose, because their tissue- 
building power is so active. Fraser reported the first case of anaemia 
treated by means of marrow, and he prefers a glycerin extract. 

J. S. Billings, Jr., recommends a similar preparation made as fol- 
lows : 

11 Twelve sheep's ribs, carefully scraped, are chopped into small 
fragments and rubbed in a mortar with one pound of glycerin. This 
is allowed to macerate for three or four days, being kept in a refrig- 
erator during that time. It is then strained through gauze, and the 
resultant liquid administered in teaspoonful doses three times a day." 

Henry F. Walker, of New York, uses a sort of emulsion made 
by mixing thoroughly the red marrow of the long bones of the ox 
with Cctraria (Iceland moss). This makes an exceedingly agreeable 
preparation, a whitish paste pleasant to the eye, and tasting not un- 
like good butter. It may be spread upon bread and eaten three or 
four times a day. 

Pcmmican is made of meat cut into slices and thoroughly dried in 
the sun ; to this are added fat, sugar, and dried fruit, such as raisins 
and currants. It is used on long voyages, especially to the Arctic 
circle, where a fatty diet is essential to furnish heat and force to en- 
able the body to withstand the rigour of the climate. It is easily 
masticated, and the sweet fruit promotes the flow of saliva. 

Calves' brains and liver contain considerable fat. 

The common fish which contain most fat are eels, salmon, her- 
ring, and mackerel. Sardines contain some fat, but derive most of it 
from the oil in which they are immersed for preservation. 

Many fish oils have special uses. The Eskimos eat whale and 
seal oil and blubber, and dugong oil is eaten to some extent in Aus- 
tralia. The oil of the sturgeon is employed for preserving caviare. 
Turtle oil and butter is made extensively in Brazil from both the eggs 
and fat of the animal (Clark). 

Cod-liver oil will be separately considered. 

Eggs contain considerable fat in their yolks. Some eggs, like the 
plover's are very rich in this ingredient. They are elsewhere de- 
scribed in detail. (See Eggs, p. 101.) 

Vegetable Fats and Oils 

The principal vegetable fats or oils and fatty foods are derived 
from seeds. Such foods are olives, olive oil, cotton-seed oil, and 
nuts. Traces of fat are found in the legumes. 

Olive Oil. — Olives and olive oil constitute a very digestible form 
of fatty food, and may sometimes be eaten by consumptives in lieu 



190 FOODS AND FOOD PREPARATIONS 

of cod-liver oil. French olives gathered while young and tender are 
very wholesome. 

Olive oil is made by crushing the fruit with stones, after which 
the pulp is pressed in bags. The first oil thus obtained is the best. 
A- second oil is got by adding boiling water to the pulp residue, and 
pressing it again. This oil is more likely to become rancid than the 
first (Clark). The best oil generally obtainable is from France and 
Italy, but an excellent quality is manufactured in Southern Califor- 
nia. The paler variety is preferable, but, unfortunately, it is con- 
stantly adulterated or imitated. (See also Olives.) Olive oil is eaten 
with salads, and is also useful for frying. 

Cotton-seed oil, and to some extent poppy-seed oil, are now fre- 
quently substituted for olive oil in the preparation of various foods, 
and the sardines which were formerly preserved in pure olive oil are, 
for the most part, immersed in cotton-seed oil. This oil is not ran- 
cid, but its flavour and odour, which resemble linseed oil, are not 
agreeable when it is eaten raw with salads or fish, and, unless ex- 
tremely pure, it leaves an unpleasant after-taste in the mouth. It is 
composed principally of palmitin and olein. It is a harmless food. 

Linseed oil is sometimes substituted for olive oil, but it is not very 
digestible. 

Cacao butter, oil of theobroma, is a firm oil obtained from ca- 
cao seeds during the manufacture of chocolate. It easily melts at 
the body temperature. It is used for inunctions and for making 
suppositories, and sometimes as an ingredient of infant foods, such 
as Lacto-preparata. 

Nuts, especially English walnuts, cocoanuts, hickory, pecan, and 
Brazil nuts, all contain a good deal of vegetable oil. (See Nuts, 
p. 190.) 

The oil of nuts which have been too long kept sometimes be- 
comes rancid and unwholesome. 

Cocoanut oil is principally used in Oriental countries. 

Peanut oil is used to some extent in this country, like cotton-seed 
oil, mainly to adulterate or imitate olive oil, which is much more ex- 
pensive. 

Java almond oil may also be used for cooking. 

Dietetic Uses of Fats and Oils. — Since fats are essential for growth 
and nutrition as well as force production, fatty food is indicated for 
convalescence from severe acute diseases, and for patients suffering 
from chronic wasting diseases, in both of which classes there has 
been considerable waste of the tissues. Persons whose general 
health has been impaired by bad hygienic surroundings, children 
who have been wrongly fed by ignorant or poor parents who could 
not obtain proper food for them, and aged persons in whom the 
nutritive processes are becoming less and less vigorous, may all be 
benefited by supplying a sufficient amount of fatty food in the dietary. 



FATS AND OILS 199 

For scrofulous and tuberculous patients fats are especially indicated. 
There is therefore a very large variety of diatheses and diseases, 
both local and general, which may be benefited by improving the 
nutrition of the body and increasing force production through the 
agency of easily digestible forms of fatty foods. 

Diseases in which Fats are Particularly Beneficial. — Tuberculosis, 
pulmonary as well as other forms ; anaemia ; chronic wasting diseases 
with secretion of pus, as empyema, chronic abscesses, etc. ; maras- 
mus ; rickets ; chronic bronchitis ; many chronic diseases of the skin 
and nervous system. 

Diseases in which the use of Fats should be forbidden or re- 
stricted. — All forms of acute gastro-intestinal disease ; chronic gas- 
tritis ; dilatation of the stomach ; chronic diarrhoea ; obesity ; fatty and 
waxy liver ; gallstones ; acne ; urticaria. 

Generally speaking, fats are laxative, and oils should not be given 
in severe intestinal disorder. 

By most persons fat cannot be eaten continuously in large quan- 
tity without producing indigestion. The stools become offensive 
and diarrhceal, there is nausea and gastric indigestion, and disgust 
for such a diet very soon arises. There are those who are unable 
to digest fats in any amount, however small, and they must derive 
all their energy from carbohydrates. 

GTycerin. — Glycerin plays an inconspicuous role as a food. It 
is mainly useful for its sweetish taste as a substitute for sugar in the 
diet of diabetics, but to many persons the taste of glycerin itself is 
nauseous. It is now largely superseded by saccharin. It is highly 
hygroscopic, and if taken in the mouth undiluted makes the mucous 
membrane sticky and unpleasant, but it is used as a mouth wash 
in a diluted form in the proportion of a drachm to the ounce of 
water. The mouth may be rinsed or swabbed with it in cases of 
acute fever, such as typhoid, where the mucous surface has become 
dried or the tongue is glazed or fissured. It acts by protecting the 
mucous membrane from evaporation, making the mouth more com- 
fortable. In such cases it sometimes diminishes thirst, although its 
effect in this respect is very uncertain. Glycerin is also laxative, 
and it may be given either per os or in the form of the well-known 
glycerin suppositories for the purpose of increasing peristaltic action 
and evacuating the bowels. It is also used as an enema. 

Cod-liver Oil 

The best cod-liver oil is known as " cold-drawn oil," and is pre- 
pared from the raw fresh livers of the codfish by subjecting them to 
heavy pressure, by which the oil is squeezed out. 

Chemical and Physical Properties. — Cod-liver oil, according to 
analyses made by De Jongh, contains glycerin, olein (70 per cent), 
15 



200 FOODS AND FOOD PREPARATIONS 

myristic, butyric, acetic, margaric, and other acids, biliary elements 
such as cholesterin. also iodine, bromine, chlorine, and phosphorus 
in small amount, and a peculiar material which is called " gaduin." 
Gautier and Mourges obtained besides a half dozen substances re- 
sembling alkaloids and other materials, a basic substance which they 
call morrhuine, about one half milligramme of which occurs in each 
gramme of the oil, and has, it is claimed, all of its active medicinal 
properties. 

The refined oil may contain no iodine, and it is seldom present 
in greater amount than 0.5 per cent : hence the value of the oil does 
not depend upon this substance, as at one time suggested. 

When pure, its odour resembles shoe leather. On adding strong 
acid, the biliary odour is intensified if the oil is unadulterated. If 
the odour is absent, the oil is spurious. 

Cod-liver oil is one of the most easily absorbed of all the oils, 
owing to the quantity of its fatty acids. It is quickly oxidised in 
the body. It is highly nutritious and alterative, and is slightly 
laxative, especially for infants. 

Some of the oil supplied in market is derived from the livers of 
other fishes than the cod, but the cod-liver oil is undoubtedly the 
best. Pains should be taken to secure a pure preparation thoroughly 
clarified from the impurities which oil may contain, such as traces of 
iodine, phosphorus, and sometimes bile salts. None of these sub- 
stances add to its food value, and, if present in excess, the oil is 
much more likely to disagree. 

The crude " straits " oil contains products of decomposition, is 
strong, malodorous, and of a dark-brown or even black colour. It 
is so disagreeable and indigestible that it possesses no advantage 
over the " shore " oil. The clarified Norwegian oil is the best variety 
to prescribe. 

Cod-liver oil is sometimes adulterated with the cheaper cotton- 
seed oil, to which a fishy flavour is artificially given, and it should 
therefore only be purchased from a well-known and responsible 
firm. 

An advantage of cod-liver oil is that when pure it can be taken 
longer than any other fat excepting butter and cream, and in larger 
quantities than those substances without disordering the stomach. 
This is no doubt owing to the fact that the oil is already in a con- 
dition in which it has once served in the animal body for nutrition 
or at least for storing up energy. This form of oil is readily emul- 
sified and saponified, and is absorbed by the intestinal villi with 
probably greater facility than any other fat. 

Dosage. — Many patients who dislike the taste of the oil at first 
soon acquire tolerance for it if given in small and gradually increas- 
ing dosage, commencing sometimes with not over 10 to 30 drops 
twice a day, and children not rarely become so fond of it as to ob- 



FATS AND OILS 201 

ject to its discontinuance. Infants may be given from 5 to 20 drops 
two or three times a day. It is so valuable a food that where its use 
is clearly indicated every effort should be made to secure its tolera- 
tion, and even though it may at first disagree, exciting nausea and 
vomiting, perseverance and care in its administration may enable it 
to be very well borne. If it is not digested at first, but one dose of 
two or three teaspoonfuls a day need be given, and this should be at 
night. 

Those who like it can sometimes take as much as an ounce three 
times a day with advantage, although half an ounce is all that can 
usually be tolerated without disturbing digestion. 

The oil must be given under proper supervision if its successful 
use is to be continued ; otherwise it defeats its own object by upset- 
ting digestion. Patients who dose themselves with it often use too 
much, and almost invariably take it at the wrong time in relation to 
meals. 

It is best to prescribe it about two hours after dinner. If given 
earlier, it remains in the stomach, interfering with the digestion of 
other food, whereas if digestion is already well under way, it passes 
with the chyme into the intestine, where it is absorbed. While the 
oil is being taken the stools should be occasionally examined, as 
the absence of fat globules in them is a proof of its complete ab- 
sorption. 

Methods of Administration. — Many patients can take perfectly 
pure, well-clarified cod-liver oil better than the emulsions and prep- 
arations in which it is offered in the market, while others prefer it 
in the form of the so-called emulsions with hypophosphites of lime, 
soda, or iron, or with other substances. Some of these emulsions are 
rendered almost tasteless, while others are flavoured with winter- 
green, ginger, or some other aromatic. 

Emulsions are seldom as good as the pure oil, and are only to be 
preferred when the latter is not digested or when the taste proves too 
nauseous. They usually do not contain above 50 per cent of the 
oil, and often only 33 per cent; hence the dose is unnecessarily 
bulky. Moreover, they rapidly deteriorate with age, so that if emul- 
sions are to be used they should be freshly made with yolk of egg 
and glycerin or mucilage of tragacanth. 

Dr. James Stewart, of Montreal, gives excellent formulae for this 
purpose as follows : 

Cod-liver oil 6 ounces. 

Oil of wintergreen 1 drachm. 

Chloroform 2 drachms. 

Glycerin, yolk of egg, each 5 " 

Orange-flower water, sufficient to make 12 ounces. 

M. Dose, one tablespoonful. 

This is not too thick. 



202 FOODS AND FOOD PREPARATIONS 

Cod-liver oil 6 ounces. 

Oil of wintergreen (or any essential oil) I drachm. 

Mucilage of tragacanth 2 ounces. 

Orange water, sufficient to make 12 " 

M. Dose, one tablespoonful. 

This emulsion is somewhat thicker than the preceding one. 

Oil of bitter almonds may be used in the proportion of three 
drops to the ounce, instead of the wintergreen oil. 

Lefaki recommends an emulsion made with an equal part of lime 
water flavoured with lemon sirup or vanilla. This can be pre- 
scribed when diarrhoea exists. Another method is to add two ounces 
of finely chopped and strained fresh pancreas to the gallon of oil to 
produce an emulsion. 

Stewart suggests rinsing the mouth before taking the oil with 
undiluted brandy or whisky and two or three drops of oil of pepper- 
mint. Children may be given a peppermint lozenge. If preferred, 
the dose of pure oil may be poured upon the surface of some fluid, 
such as orange or ginger bitters, strong black coffee, lemon juice, 
weak brandy and water, or even ale or beer. Pains should be taken 
to float the oil in the centre of the surface of the fluid, so that it is 
to some extent coated by it and does not come in contact with the 
glass or cup and produce a lingering, disagreeable taste in the mouth. 
Ringer suggests adding a few drops of catsup to disguise the taste, 
or the use of a mixture of equal parts of the oil and fresh aqueous 
solution of gum acacia with two minims of oil of lemons added to 
each ounce. A little salt taken in the mouth before and after each 
dose may neutralise the taste. He also refers to the use of a cod- 
liver-oil jelly containing 70 per cent of the oil. This disguises the 
flavour. The oil is sometimes given with different preparations of 
meat juice. 

In this country cod-liver oil is extensively used in the form of 
capsules of gelatin which are shaped like an olive, and which some 
patients can swallow with ease, although they are rather bulky and 
not always reliable. A child of ten years came under my observa- 
tion who for some time previously had been given four or five of 
these capsules daily, each containing a teaspoonful of cod-liver 
oil. She had developed an exceedingly irritative stomach cough, 
for which a variety of sedatives had been administered without any 
effect. To my astonishment, she at one time vomited seventeen of 
the undissolved capsules, which represented four or five days' dosage. 

The oil is sometimes administered in the form of " oleochyle," 
in which it is claimed it has been predigested and rendered easier of 
absorption. 

Claude Bernard, to whom we are indebted for much valuable 
research upon the physiology of digestion, first showed that ether 
given by the mouth acts as a stimulant to the secretion of the pan- 



FATS AND OILS 203 

creas and the glands of Brunner which aid the digestion of fat, and 
that it increases the absorption of fats. Acting upon this sugges- 
tion, Dr. Balthazer Foster found that pure ether added to fats and 
oils in the proportion of five or six minims to a drachm of the oil 
would often insure its digestion, whereas previously it had excited 
nausea and vomiting, and this method has proved of service in the 
hands of others. The ether itself disguises somewhat the taste of 
the oil, but I have sometimes found it to produce disagreeable eruc- 
tations. In fact, in some hospitals a " malingerer's mixture " has 
been employed composed of a disagreeable combination of ether, 
oil, and asafcetida, which has the result of causing eructations and 
maintaining an exceedingly disagreeable taste in the mouth. Lime 
water is sometimes added to cod-liver oil to produce a temporary 
emulsion, and it may prevent nausea. 

Cod-liver oil is advantageously combined with malt, and when 
not so sweet as to be disliked by the patient it proves a very service- 
able food. Cod-liver oil is added in the proportion of 30 per cent to 
maltine, or 50 per cent to malt extract. 

In very hot weather it is usually best to suspend the administra- 
tion of oil, as it is liable to disagree, even if it does not become rancid. 

Substitutes. — Many substitutes for cod-liver oil have been pro- 
posed, but it is doubtful whether any of them can be made to yield 
all the benefits to be derived from the genuine substance. 

Efforts have long been made to determine whether the alkaloidal 
or other substances obtainable from cod-liver oil do not possess all 
the nutritive and stimulating properties of the oil itself in equal or 
even greater degree. Some of them are doubtless capable of pro- 
ducing active symptoms, but if the oil itself is a true food, there can 
be no advantage in attempting to concentrate it beyond the minor 
consideration of avoiding its nauseous, fishy taste. M. Chapoteau 
describes a crystalline substance which he terms morrhuol, and 
which exists in the oil in the proportion of 1.5 to 6 per cent, the 
lesser quantity being found in the purest oil. It is claimed that three 
to five drops of this substance possess all the properties of a drachm 
of cod-liver oil. It may be given in capsules or disguised with 
olive oil, fat, or cream. Much interest is at present manifested in 
testing the clinical worth of preparations of this class, but although 
their use has been favourably reported by some observers within the 
past year or two, further evidence is required before their general 
substitution for the oil itself can be indorsed. 

Von Mehring and Hauser recommend " lipanin," made by add- 
ing to olive oil 6 per cent of oleic acid. This is devoid of disagree- 
able taste and odour, and may be given in doses of from one to four 
teaspoonfuls three times a day. 

Uses. — Cod-liver oil is not a specific for any disease, and there 
are many clinicians who prefer to prescribe other forms of fat when 



204 FOODS AND FOOD PREPARATIONS 

possible. Fothergill wrote that " out of five persons taking cod-liver 
oil probably only two require fat in that particular form, while three 
take it because it is the only fat put up in such a form as can be 
readily purchased." 

Nevertheless, there are often seen cases of phthisis in which a 
decided gain in weight follows the administration of a disproportion- 
ately small quantity of the oil. It is a most useful food in many 
conditions of debility, and is indispensable in the treatment of rickets 
and general tuberculosis. 

It is found clinically to be of great service in a variety of forms 
of chronic inflammation and in cases in which there is old purulent 
discharge from any part of the body, as from the middle ear, or from 
a chronic abscess, like empyema, and in chronic bone diseases, such 
as caries. 

Among other chronic diseases for which cod-liver oil is recom- 
mended may be mentioned chronic rheumatism and gout, arthritis 
deformans, a variety of skin affections, and advanced syphilis. It 
is of service also in pulmonary emphysema and in cases of chronic 
bronchitis with tenacious purulent expectoration, and by many it is 
believed to be of some specific value in loosening cough. It should 
be observed that oil when absorbed passes through the lymphatic 
system and is carried with tolerable directness into the pulmonary 
circulation, where fats in general are believed to be oxidised. It is 
suggested that this fact may possibly have some bearing on the in- 
fluence attributed to cod-liver oil as an expectorant, although it 
seems more probable that the effect is derived from the improvement 
produced upon the general nutrition. Brunton attributes it to a 
stimulating action upon the epithelium of the bronchi.. In cases of 
atonic dyspepsia, particularly among elderly people, cod-liver oil 
often relieves the " sinking " feeling at the epigastrium and the faint- 
ness of which they complain. 

Ringer recommends cod-liver oil for vertigo in the aged which 
originates from feeble heart action, and for chronic endocarditis in 
children. It is also serviceable in relieving constipation in young 
infants, and it may be sometimes given with advantage in lieu of cas- 
tor oil. Its loosening effect is more decided in children than in 
adults, and it is less likely to produce subsequent constipation than 
castor oil, besides being less disagreeable to take. 

For marasmus the use of cod-liver oil is particularly indicated, 
and in infants when chronic diarrhoea obtains, some benefit may be 
derived from the topical application of the oil to the skin. To tuber- 
culous children of the emaciated marasmic type in whom the skin is 
dry and wrinkled 15 or 20 drops of the oil may be given at night 
without fear of increasing the diarrhoea. 



PART II 
STIMULANTS, BEVERAGES, CONDIMENTS 



STIMULANTS AND BEVERAGES 

It is the almost universal experience of mankind that the taking 
of food and drink merely to satisfy the cravings of physical needs 
does not at the same time wholly satisfy the desire of the mind for 
occasional invigoration, for restoration of bodily function after fa- 
tigue, for support during sustained muscular exertion, for an incen- 
tive to activity, and for conviviality. In some form or other, 
although in greatly varying degree, a stimulant is demanded by 
almost every one to meet the emergencies with which he is from time 
to time confronted. 

To this end the civilised European imports his tea from China, 
his coffee from Java, his cocoa from Brazil, his tobacco from America 
or Cuba, his opium from India, and his alcohol from more immediate 
neighbours. His semicivilised or wholly barbaric brother who lacks 
the ability or means to procure such refreshment from foreign 
sources relies upon his own ingenuity to devise fermented drinks 
from every available substance. Thus, the Tartar ferments milk into 
koumiss, the Mexican ferments the Maguey (Agave Americana) into 
pulque, the Central African ferments a wine from the palm, the 
Apache of southern Arizona ferments a cactus into the intoxicating 
mescal, the Kamtchatkan ferments a peculiar drink from a poison- 
ous fungus, and honey, rice, corn, barley, rye, grapes, dates — in fact, 
nearly every cereal and every fruit — is in some part of the world 
made to yield the cup which cheers, and too often inebriates as well. 

It is true that there are those who find it possible to live without 
ever tasting even the mildest stimulants of any kind, and there are 
sects of men, like the Mohammedans and Buddhists, to whom the 
use of alcohol in every form is absolutely forbidden by their religion ; 
but most of them discover other means of satisfying an instinctive 
craving for occasional stimulation, and ready substitutes for the 
prohibited intoxicants are found close at hand in hasheesh, opium, 
excessive tea consumption, etc. The economic and social aspects 

205 



2o6 STIMULANTS, BEVERAGES, CONDIMENTS 

of this subject alone are of vast importance, and the question of the 
utility of stimulants and beverages is in itself no small branch of 
dietetics. 

The several substances classed under these headings are found to 
serve in one or more of the following ways : 

I. To relieve thirst and introduce fluid into the circulation. 

II. As diuretics. 

III. As diaphoretics. 

IV. As diluents of the food and of the waste material in the body. 

V. As stimulants of the nerves and other organs. 

VI. As intoxicants. 

VII. As demulcents. 

VIII. As tonics, and to promote digestion. 

IX. As astringents. 

X. For nutrition. 

The effects of all beverages and stimulants are far more pro- 
nounced if they are taken into an empty stomach, which insures their 
prompt absorption. 

I. To relieve thirst all fluids which are not too sweet may be used, 
but sour beverages, such as acid lemonade or raspberry vinegar, the 
effervescing carbonated waters, solutions of potassium bitartrate, or 
dilute mineral acids in water, are generally the most acceptable. 

II. As diuretics the mineral waters and carbonated waters hold 
the first rank. With many persons coffee is also an active diuretic. 
So are beer, gin, champagne, and, to a lesser degree, other forms of 
alcohol, and tea. 

III. As diaphoretics, hot spirits and water or hot tea may be 
used. 

IV. As diluents of the ingested food and of the waste material of 
the body the alkaline and carbonated effervescing or bland waters 
are the best. 

V. As stimulants of the nerves and other organs, the milder 
forms of alcoholic beverages, diluted spirits, tea, and coffee are used. 

VI. As intoxicants, beers, ales, strong wines, champagne, and 
strong liquors are the most powerful agents. Koumiss as originally 
made in the steppes of Russia, and many fermented substances, are 
also employed for the same purpose. 

VII. As demulcents, mucilaginous, farinaceous, and gelatinous 
beverages are used for fevers, etc. Such are decoctions of Iceland 
moss (cetraria) or Irish moss, barley or oatmeal water, arrowroot and 
other light gruels, solutions of gelatin, flaxseed tea, etc. When 
taken hot they are soothing for coughs and promote expectoration. 

VIII. For use as tonics and to aid digestion may be mentioned 
malt extracts, ales, light wines, clarets, Burgundies, diluted brandy 
or whisky, chalybeate and arsenical waters, and alkaline waters 
drunk before meals. 



. ; STIMULANTS AND BEVERAGES 207 

IX. As astringents, red wines and tea are of chief importance. 

X. For nutrition, cocoa, chocolate, malt extracts, " grape food," 
and, because of the milk or cream added, tea and coffee. 

Stimulants have two separate actions : First, a prompt exhilarat- 
ing effect or exaltation of the nervous system, which endures for a 
few hours, and, secondly, a period of depression which usually bears 
a more or less definite relation to the degree of previous excitation. 
The second period is sometimes longer or more intense than the 
first, producing an actual balance of loss of vitality in the system. 

Various dietetic drinks have been advocated for their supposed 
specific action in stimulating a torpid liver and as laxatives or as 
diuretics; such, for example, are various " herb teas," etc., but they 
are of doubtful efficacy. 

Many fruit essences and sirups are offered for sale for use in 
making cooling drinks and invalid beverages. When thoroughly 
reliable preparations are obtained they are of good service, but 
many of them are adulterated. For example — for lemonade, mix- 
tures of malic, citric, and tartaric acids are often substituted. As a 
rule, it is better to extract the juice from the fresh fruit, and unless 
large quantities are required, this is almost as cheap. Unfermented 
California grape juice may be had in very pure condition, and it 
constitutes an excellent beverage for invalids, being wholly free 
from alcohol. " Grape food " serves a similar purpose (p. 185). 

The preparations under consideration may be diluted with ice 
water, or with any one of the simple effervescing waters, such as 
carbonic-acid water, Vichy, Seltzer, Apollinaris, etc. 

Of all these beverages, lemonade and orangeade are perhaps the 
most useful in the sick-room. These are agreeable, cooling, and 
refreshing in fevers, mildly diuretic, and beneficial in many ways. 
A very wholesome drink is made by putting the juice of two lemons 
with three or four lumps of sugar into a tumbler of iced Vichy, 
Seltzer, or Apollinaris, and stirring in a saltspoonful of bicarbonate 
of sodium ; to be drunk while effervescing. 

Root beer, sarsaparilla, and ginger ale are wholesome beverages 
when pure. Ginger ale is likely to cause colic unless a reliable article 
is obtained from a trustworthy dealer. It makes a useful " long- 
drink " for alcoholic subjects who are attempting to recover from a 
debauch. They crave some beverage which has life and sparkle, 
and the ginger itself is helpful to the stomach. 

Alkaline and Mineral Waters — Effervescing Waters 

There are many spring waters which are used as beverages and 
drunk either with or between meals. They possess, in addition 
to the properties of plain water, a mildly tonic effect upon the 
mucous membrane of the stomach, due either to the carbon-dioxide 



208 STIMULANTS, BEVERAGES, CONDIMENTS 

gas or salts, or both, which they may contain, and, owing to their 
salts and water, they are also diuretic. Many of these waters are 
sold " plain " — i. e., without free gas, and others either hold natural 
C0 2 or are made " sparkling " by having this gas pumped into them 
under pressure. 

These waters are very useful, when taken half an hour before 
meals, to cleanse the mucous membrane of the stomach and pre- 
pare it for the reception of food. They also serve to dilute and 
wash out waste materials from the system. 

The effervescing or carbonic-acid waters are more highly 
charged with gas as sold from " fountains " at the druggists' or in 
siphons than when bottled. 

Fruit sirups are combined in many ways with soda, carbonic- 
acid, or other effervescing waters, to make soda water and similar 
beverages. 

Ginger ale, sarsaparilla, etc., are made effervescing, and are often 
used as cooling and refreshing drinks. 

The habit which some persons form of drinking large quantities 
of alkaline waters independent of any special needs of the system 
should be condemned. It leads to the condition which Trousseau 
long ago described as " mineral-water cachexia." 

All the effervescing waters when taken in excess are apt to ex- 
cite or increase flatulency and give rise eventually to dyspepsia and 
debility, especially when combined with sweet sirups. They should 
be avoided in dilatation of the stomach, flatulent dyspepsia, and 
palpitation. 

Some waters are drunk for their laxative or purgative action, 
and others for the salts which they contain, like those of sulphur, 
iron, or arsenic. This leads to the classification of mineral waters 
into alkaline, saline, chalybeate, sulphurous, acidulous, arsenical, etc. 

Thermal waters are those which issue hot from their springs. 
Many persons believe that these waters possess special properties 
by virtue of being hot, which they lose as the heat departs, but there 
is no physiological ground for this belief. 

Many table waters, like Poland water (a plain carbonic-acid 
water), Vichy, Johannis, Apollinaris, and Seltzer (effervescing car- 
bonic-acid waters), are used mainly as an agreeable table beverage, 
and to dilute spirits, wines, lemonade, etc. They are cooling, re- 
freshing, and wholesome. People will often drink fluid of this kind 
who are not willing to drink sufficient plain water. 

Johannis water is an alkaline carbonated water which comes 
from a spring at Zollhaus, in the Taunus Mountains. It contains 
principally carbonates of lime, soda, and magnesia, besides traces 
of other materials, and considerable free carbonic-acid gas. 

A glass of Apollinaris or similar water taken an hour after a 
too heavy dinner promotes digestion and helps remove waste prod- 



STIMULANTS AND BEVERAGES 200, 

nets from the system. In fevers such waters are always useful, and 
they may be given very freely. They often allay nausea and vomit- 
ing. They may be employed for the dilution of liquors and milk 
for invalids. Some persons can digest milk better when diluted with 
Vichy, carbonic-acid water, plain soda water, or Seltzer. The addi- 
tion of the latter tends to overcome the constipation which milk is 
apt to cause. 

Some waters are sold as natural lithia waters, but the quantity 
of lithium contained in any spring water is usually very minute, 
and beverages of this class are generally re-enforced artificially by 
lithium salts. They are used to counteract the lithic-acid diathesis, 
gout, and rheumatism. 

Kronenquelle water is an alkaline lithia water from Obersalz- 
brunn, in Silesia, which contains considerable sodium carbonate and 
traces of iron and manganese. 

The Buffalo, Londonderry (New Hampshire), and other lithia 
waters are much prescribed in this country. 

Below is given a list of some of the more noted waters which 
are extensively used in conjunction with dietetic treatment : 

1. Alkaline Waters. — Vichy, in France; Ems, in Germany; 
Fachingen, in Germany ; Saratoga Vichy (rich in C0 2 ), New York ; 
St. Louis Springs, Michigan (poor in C0 2 ) ; Bethesda Springs, Wis- 
consin. 

Other sodium chloride waters, containing also carbonates and 
C0 2 , are those of Hathorn Spring, Congress Spring, and Kissengen 
Spring, in Saratoga, New York ; Homburg, Wiesbaden, Kissengen, 
and Seltzers, in Germany ; Bourbonne, in France. 

The alkaline waters all contain more or less carbon dioxide, 
and their most important ingredients are the alkaline carbonates. 

They also contain sodium chloride, and sometimes sodium sul- 
phate. Some have one variety of salts, some another, which pre- 
ponderates. Generally speaking, the European waters are richer in 
alkalies than are the American. 

Alkaline waters are useful in the uric-acid diathesis and lithsemic 
conditions, gout, chronic rheumatism, obesity, hepatic engorgement, 
gallstones, hyperacidity of the gastric juice, chronic gastric ulcer, 
and catarrhs of the mucous membranes, especially of the stomach, 
respiratory tract, and bladder. 

2. Alkaline Sulphur Waters. — Richfield Springs, Sharon Springs, 
Avon Springs, in New York ; Greenbrier White Sulphur Springs, 
in West Virginia ; Harrogate, in England ; Neuendorf and Meinberg, 
in Germany ; Aix-la-Chapelle, in Rhenish Prussia. 

These waters, containing sulphuretted hydrogen in addition to 
other ingredients, are much used in gout, chronic rheumatism, 
obesity, and chronic eczema. They are often supplemented by a 
course of chalybeate waters. 



2IO STIMULANTS, BEVERAGES, CONDIMENTS 

Hot springs are found at the Hot Sulphur Springs of Arkansas 
and Virginia, and Schlangenbad and Plombieres, in Europe. 

3. Alkaline and saline purges contain a high percentage of sodium 
and magnesium sulphates. These waters are often called " bitter 
waters. 1 ' 

Such are : Piillna, in Bohemia (the strongest of all, and one of 
the oldest known) ; Carlsbad (Sprudel) and Marienbad (Kreuz- 
brunnen), in Bohemia ; Friedrichshall, in Germany ; Franz Josef, in 
Austria ; Kissengen Bitterwater, in Bavaria ; Hunyadi Janos, in 
Hungary ; Rubinat Condal Spring and Villacabras, in Spain ; Epsom , 
in England; Crab Orchard, Estill Springs, in Kentucky; Bedford 
Springs, in Pennsylvania ; some of the Saratoga waters, and Mount 
Clement Spring, in Michigan, which latter water contains iron. 

These waters are useful to counteract indiscretions in diet and 
the overloading of the liver. 

The Rubinat water is effective and possesses the advantage of 
being less disagreeable than many of the others. 

Villacabras water is a Spanish sodium sulphate, strongly purga- 
tive water, obtained not far from Madrid. 

These waters should be taken either very cold or in a half-pint 
of very hot water. If drunk lukewarm their taste is nauseous, and 
may excite emesis. The dose varies from two to six or eight 
ounces. 

4. Chalybeate Waters. — Schwalbach (Stahlbrunnen), Pyrmont 
(Neubrunnen) Spa, Belgium ; St. Moritz, Switzerland ; Rock Enon, 
Virginia. These waters serve as tonics for the blood and nerves, 
but if too long used they cause dyspepsia and anaemia. 

5. Acidulous waters contain C0 2 in excess, and but little salts 
of any kind. Such are the waters of Clysmic Spring, in Wisconsin; 
Blue Lick, in Kentucky; Carlsbad (Dorotheenquelle), in Bohemia. 

6. Various waters are the Alum Springs, in Virginia ; Oak 
Orchard Acid Spring, in New York ; Bourboule, in France, which 
contains arsenic. Roncegno water is a ferruginous arsenical water 
from the Tyrolean Province of Trent. 

Tannin 

Tannin is an astringent of vegetable origin which exists in tea^ 
coffee, and many wines, especially the red wines, and as such it is 
worthy of brief separate consideration. It possesses no nutrient 
power whatever, and is mainly of interest to the dietetist from the 
harm it may occasion if taken too freely. In strong solution it 
precipitates the ferment of the gastric juice and renders it inert, 
and also gives rise to constipation by its astringency, which affects 
the mucous membrane of the intestine. For these reasons strong 
tea or tea drunk to excess materially hinders gastric digestion. 



STIMULANTS AND BEVERAGES 



211 



According to Fraser, the tannin in tea interferes with the diges- 
tion of fresh meat, but to a less extent with that of dried or smoked 
meat, such as tongue or ham, the fibres of which are already shrunk- 
en by curing. 

Coffee contains much less tannin than tea, thus it has not the 
same effect upon the alimentary canal, in fact, it may be laxative. 

Tannin is contained in red wines in considerable quantity, hence 
clarets are mildly astringent and constipating. 

Tannin is useful for a variety of local astringent applications. 

Tea 

Method of Preparation. — Tea is a preparation made from the 
leaves of various species of a hardy evergreen shrub called Thea. 
The manufacture consists in plucking the young leaves of the plant 
and placing them in the sun ; after they have become withered they 
are rolled and twisted. This process is sometimes conducted by 
hand, or even by the feet of the natives in China, and sometimes by 
machinery. The leaves are next pressed into small masses or rolled 
into balls and allowed to ferment while still moist, after which they 
are dried over a fire of a temperature sufficient to evaporate all the 
moisture. They are finally sifted and assorted into different quali- 
ties. The value of the tea depends upon its flavour, and this is 
mainly influenced by the process of fermentation, which must be 
supervised with great care. 

Green and Black Tea. — The distinction between black and green 
teas is due to the variations in their mode of preparation, and not 
to separate species of the plant. Green tea is made by steaming 
the leaves before they are rolled and dried. The further difference 
between green and black tea consists in the relatively larger quan- 
tity of astringent material (tannin) which predominates in green 
tea. The following table, from an analysis by Mr. Y. Kozai, illus- 
trates this point and exhibits the proportionate quantity of some of 
the more important ingredients of tea. It presents the difference 
in percentage composition between green and black tea prepared 
from the same plant : 



Crude protein. 

Fibre 

Ash 

Theine 

Tannin 

Total nitrogen 



Green tea 


Black tea. 


37-43 


38.90 


IO.06 


IO.07 


4.92 


4-93 


3.20 


3-30 


IO.64 


4.89 


5-99 


6;. 22 



Because green tea contains more than twice as much of the 
astringent tannin than black tea it is generally regarded as less 



212 STIMULANTS, BEVERAGES, CONDIMENTS 

wholesome than the latter. It is also believed to have a somewhat 
less stimulating effect upon the nervous system, though this can 
hardly be accounted for by the slight variation in the percentage of 
theine shown to exist by the above table, this latter substance being 
the alkaloid, which is chiefly responsible for the stimulating influence 
of tea upon the nerves. 

There has been some discussion in regard to the identity of theine 
with caffeine, and by many writers they are believed to be the same 
alkaloid. Rice says that most of the commercial caffeine is derived 
from tea leaves, but May finds that in frogs, at least, " theine pro- 
duces spontaneous spasms and convulsions, while caffeine does not. 
Theine impairs the nasal reflex early in the poisoning process, while 
caffeine does not, if at all, until the very last stage." 

Properties. — The peculiar stimulating properties which tea pos- 
sesses, as well as its colour and agreeable flavour, depend upon the 
season of the year at which the leaves are gathered, the variety of 
the plant, the age of the leaves, which naturally become tough as 
they grow older, and the care exercised in their preparation. The 
flavour is produced by the formation of volatile oils which develop 
during fermentation. It is these substances which cause the minor 
differences in effect of tea and coffee. 

The aroma as well as the flavour of tea is often artificially in- 
creased by the addition of such substances as the leaves of orange 
flowers, jasmine, or roses. 

Tea made of small leaves packs closely, and if measured by the 
spoonful gives a stronger beverage than the coarser-grained vari- 
eties. 

Infusion. — The flavour of tea depends not only on the character 
of the leaves, but upon that of the water which is added to them. 
About five grammes of leaves should be used for one infusion. The 
water should be poured upon the tea leaves when boiling, and the in- 
fusion should not last beyond three or four minutes if the flavour is 
to be delicate ; if it is continued beyond this point materials become 
extracted from the leaves which, while they may make the tea ap- 
pear stronger, materially diminish the delicacy of its flavour. The 
water should be neither too hard nor too soft. Soft water extracts 
more of the soluble materials of the leaves and yields a beverage of 
darker colour. Water which contains iron or lime salts should be 
boiled with sodium carbonate before it is used for tea infusion. 



PHYSIOLOGICAL AND THERAPEUTIC ACTION 

Good Effects. — Tea is mildly stimulating to the nervous system 
and tends to increase the activity of certain vital functions. It is re- 
freshing and relieves bodily fatigue. For the latter purpose it has 
been found especially useful for soldiers on the march in hot climates. 



STIMULANTS AND BEVERAGES 



Major Woodruff, U. S. A., says : " The universal experience of 
military men testifies to the absolute necessity of tea or coffee. The 
latter is generally preferred, but the writer's experience points to 
tea as preferable in the long run." For this purpose both these 
substances are better preserved if compressed into small bulk. 

In some persons a cup of hot tea affords prompt and decided re- 
lief from headache, and when taken quite strong it is sometimes serv- 
iceable in the cure of chronic alcoholism. It is also used as an 
antidote for opium poisoning, but coffee is preferable. 

The " strength " of tea as applied to the appreciation of its taste 
in distinction from its effect on the nerves is due to the quantity of 
tannin present, which is bitter. A bitter tea is not therefore neces- 
sarily a strong one in its stimulating properties, which are owing to 
the theine. 

Tea, when employed as a beverage, possesses some effects which 
are not strictly due to action upon the nerves. It introduces con- 
siderable hot water into the system, which is beneficial when taken at 
the proper time in relation to meals, and wdien milk or cream and 
sugar are added its nutritive value becomes considerable. Tea is 
moderately sudorific in action, and it has a slight influence in regulat- 
ing the circulation and temperature of the body, which, if too cold, 
becomes warm by the stimulating effect upon the heart, whereas if 
the body is too hot, tea may exert a cooling influence by increasing 
perspiration and evaporation from the surface. Hot tea will some- 
times increase the action of aperients, but it is doubtful whether it 
has any more effect than a similar quantity of hot water. 

Roberts gives the following analysis of 

The Effects of Tea and Coffee on Gastric Digestion 

Digesting mixture : 2 grammes of dried beef fibre, 0.15 c. c. hydrochloric acid, 1 c. c. 

glycerin extract of pepsin, varying proportions of tea and coffee, water to 100 c. c. 



Proportion of Tea or Coffee 


TIME IN WHICH DIGESTION WAS COMPLETED. 
(NORMAL, IOO MINUTES.) 


contained in the digesting 
Mixture. 


Tea, 5-per-cent 
strength. 


Coffee, 5-per-cent 
strength. 


Coffee, 15-per-cent 
strength. 


10 per cent 


105 minutes. 
140 " 
180 
Embarrassed. 


105 minutes. 
140 " 

180 
Embarrassed. 


160 minutes. 


20 " " 


Embarrassed. 


40 " " 

60 " " 


Almost no action. 







Many elderly people find tea particularly grateful and soothing 
after reaching a period of life when the functional activity of the 
stomach is gradually weakened. A disproportion may exist between 
the quantity of food which the stomach can digest and the actual 
need of the body for nutritive materials to counterbalance the daily 
waste. In such cases tea enables the aged poor to live on less food 
than they would otherwise require, and is thus economical for them. 



214 STIMULANTS, BEVERAGES, CONDIMENTS 

The refreshing effect of tea when taken into an empty stomach 
after bodily fatigue may continue between three and four hours, a 
period considerably longer than that of coffee or light wine. 

Ill Effects. — The ill effects of excessive tea drinking — the " tea 
habit "—are referable to its action on the digestive and nervous 
systems and are cumulative. If taken in large quantities with meals, 
tea precipitates the digestive ferments, retards the activity of diges- 
tion, and may even occasion gastric irritation and catarrh. Consti- 
pation usually results, though there is sometimes diarrhoea, and 
more or less flatulency. The latter may itself cause insomnia. The 
effect of the " tea habit " on the nervous system is to overstimulate 
and then depress it, first producing restlessness, worry, and insomnia, 
and finally muscular tremors, sensory disturbances, and palpitation. 
Persons who are subjected to some unusual strain or anxiety find 
that tea for the time being disagrees with them, whereas they are 
able to drink it regularly when in ordinary health. Cheap teas are 
always much more apt to produce ill effects than the more expensive 
varieties. In many persons five cups of strong tea per diem pro- 
duce symptoms of the " tea habit." 

Indian teas contain a larger proportion of tannin than do those 
from China. For this reason they are more likely to produce disor- 
ders of digestion and constipation. They also occasion nervousness 
and sleeplessness to a marked degree when drunk in excess. 

The ill effects of poor tea and of tea rich in tannin can be over- 
come in some degree, as suggested by Roberts, by the addition of 
carbonate of sodium in the proportion of ten grains to the ounce of 
dried tea leaves ; this does not materially interfere with the taste. 

When tea taken with milk and sugar is found to disagree, sub- 
stitution of the juice of a slice or two of lemon makes it accepta- 
ble and beneficial to many persons. Tea which is " steeped " is 
more unwholesome on account of the extra tannin, etc., which is 
extracted. 

Tea must be avoided in dyspepsia, gastric irritability from any 
cause, constipation, anaemia, insomnia, and " nervousness," and 
usually in gastric catarrh, although Bauer recommends weak tea as 
less likely than coffee to induce heartburn or aggravate diarrhoea. 
The ill effects of the " tea habit " are even more pronounced in 
children and youth than in adults. 

A case of multiple neuritis caused by drinking between two and 
three pints daily of strong tea has been reported by Spratling, and 
several similar cases are recorded. 

In a recent report upon insanity in Ireland tea is mentioned as a 
contributing factor. A very poor quality is there used, and it is often 
stewed nearly all day, water being added from time to time. This 
report continues : " Undoubtedly the method of preparation adopted 
and the excessive use of this article of diet, now so general among 



STIMULANTS AND BEVERAGES 21 5 

our poorer population, tends to the production of dyspepsia, which 
in its turn leads to states of mental depression highly favourable to 
the production of various forms of neurotic disturbance." Excep- 
tionally the " tea habit " has been acquired through chewing the 
leaves. 

Adulteration of Tea. — The adulteration of tea is extensively 
practised, but it can rarely be said to be injurious to the digestion, 
for the adulterants are either added in very minute proportion, as in 
the case of plumbago, indigo, or Prussian blue,, for the purpose of 
colouring or " facing " the tea, or foreign leaves are mixed with the 
tea, which simply dilute it without necessarily making it injurious. 
Green tea is more likely than black to be adulterated. Catechu as 
well as salts of iron are sometimes added to increase the astringency. 

Quantity Consumed. — It is interesting to make a comparison 
between the consumption of tea and coffee in the United States. 
The quantity of tea consumed in 1890 was 83,494,956 pounds, while 
the consumption of coffee during the same period was 490,181,755 
pounds. On the other hand, London consumed per annum 25,000,- 
000 pounds of tea (or 1.38 pound per capita) as against 2,740,000 
pounds of coffee (1898). The amount of tea consumed per capita 
in the United States is 1.33 pound, while the amount of coffee con- 
sumed is 7.8 pounds. Slightly more than half of the tea drunk in 
the United States comes from China, and a large part of the re- 
mainder from Japan. The India teas are nearly twice as strong as 
the others, but they are much less commonly drunk in this country 
excepting in mixtures where they have been added to Chinese or 
Japanese teas to improve their flavour and strength. 

Coffee 

Composition. — Coffee consists of the berries or seeds of Coffca 
arabica, which are dried, roasted, ground, and subjected to infusion. 
The coffee drunk in the United States is mainly imported from 
South and Central America, Mexico, and Java, 63 per cent being 
imported from Brazil. The Rio berry is smaller than that from 
Java. The composition of coffee beans varies somewhat, but an 
approximate idea of it is obtained from the following table from 
Konig, which gives the percentage of the important ingredients : 

Water 115 

Fat 14 48 

Crude fibre 19.89 

Ash 4-75 

Caffeine 1 . 24 

Albuminoids T 3-98 

Other nitrogenous matter 45 -°9 i 

Sugar, gum, and dextrin 1 . 66 

16 



2l6 STIMULANTS, BEVERAGES, CONDIMENTS 

The exhilarating effect of coffee is said to be caused by the ingre- 
dients caffeine, caffeotannic and caffeic acids, and a volatile oil de- 
veloped during roasting. 

The coffee berry contains no starch, and Wiley has shown that 
its principal carbohydrate is cane sugar or sucrose. There are pres- 
ent also a substance allied to dextrin and a reducing sugar. The 
well-known stimulant effect of coffee upon the nervous system is 
mainly due to the alkaloid caffeine, which is chemically identical 
with theine and possesses the same physiological properties, its 
action being chiefly upon the nerves and kidneys. Coffee also con- 
tains a little aromatic oil which is moderately stimulating to the 
nervous system. It has less oil than tea. 

Method of Preparation. — The preparation which the coffee beans 
require consists of drying them by roasting at a temperature of 
fully 200° C, after which they are ground into small fragments to 
facilitate the solution of their ingredients by hot water. The heat 
converts the sugar of the beans into caramel and develops vola- 
tile and aromatic substances to which the agreeable aroma of the 
coffee is due. These substances being volatile, the aroma soon for- 
sakes the beans, and they should not be roasted or ground long 
before they are to be used. The roasting also liberates gases in the 
beans, which cause them to increase in bulk while losing in weight. 

The methods of preparing coffee as a beverage are three — 
namely, (i) filtration, (2) infusion, and (3) decoction or boiling. 

(1) In filtration boiling water is allowed to percolate slowly 
through finely ground coffee. Air should be excluded as much as 
possible during the process ; otherwise the oxygen alters the aroma. 
According to von Liebig, filtration only dissolves from n to 15 per 
cent of the coffee instead of 20 or 21 per cent, which is obtainable 
by other means. 

(2) Infusion is the common mode of preparation of coffee em- 
ployed in this country and in Europe. It is said to reduce the ex- 
citing influence of strong coffee without destroying its aroma or 
otherwise altering it. In conducting this process the finely ground 
coffee is put into water previously boiled, but removed from the 
fire, and allowed to stand for about ten minutes at a temperature of 
180 or 190 F. 

(3) Decoction is the method principally used in Turkey and else- 
where in the East. The coffee beans are ground to powder and 
placed in cold water, which is then heated to boiling. The beverage 
is drunk without straining. If boiled but a few minutes some aroma 
still remains, but it is soon driven off, and continued boiling extracts 
more caffeine than is obtainable by infusion. 

Coffee long boiled or left standing in the coffee pot over the fire, 
as in the case of tea, becomes more and more indigestible from 
extraction of tannin. 



STIMULANTS AND BEVERAGES 217 

Soft water extracts more coffee from the berries than hard, as 
it does from tea leaves. 

Coffee should always be made from newly roasted and ground 
beans ; and when economy is to be considered, or when strength and 
aroma are both desired, a larger proportion of the soluble ingredients 
may be obtained by combining the second and third processes, as 
described by Yeo : " After first preparing an infusion by passing 
boiling water over the coffee, the grounds left should be boiled in 
more water, and the boiling decoction thus obtained should be 
poured over another portion of freshly ground coffee ; this, in turn, 
is also boiled with more water, to be used again with fresh coffee in 
the same manner, and so on. By this method all the soluble matters 
in the coffee are extracted and none of the aroma is needlessly dis- 
sipated." Ready-made coffee is sometimes preserved with con- 
densed milk and sugar in tin cans. This preparation merely requires 
to be put into a cup of hot water to be fit for drinking. 

PHYSIOLOGICAL ACTION 

Good Effects. — Coffee, when taken as a beverage, has well- 
marked physiological effects, chiefly upon the muscular, vascular, 
and nervous systems. It removes the sensation of fatigue in the 
muscles and increases their functional activity ; it allays hunger to 
a limited extent ; it strengthens the heart action, and constitutes a 
valuable cardiac stimulant in some forms of collapse by its moderate 
quickening effect upon the pulse and influence upon the vascular 
tone ; it acts as a diuretic, and increases the excretion of urea ; it 
has a mildly sudorific influence ; it counteracts nervous exhaustion 
and stimulates nerve centres. It is used sometimes as a nervine in 
cases of migraine, and there are many persons who can sustain pro- 
longed mental fatigue and strain from anxiety and worry much 
better by the use of strong black coffee. In low delirium, or when 
the nervous system is overcome by the use of narcotics as in the 
case of opium poisoning, or by alcohol, or by excessive haemorrhage, 
strong black coffee is serviceable to keep the patient from falling 
into the drowsiness which soon merges into coma. In such cases as 
much as half a pint of strong black coffee may be injected into the 
rectum. 

Drunk in moderation, coffee is a mild stimulant to gastric diges- 
tion. In the bowels coffee has an opposite effect to that of tea, for 
it stimulates peristalsis, and for many people, when drunk early in 
the morning, it possesses a distinctly laxative effect. It thus in- 
directly benefits the liver. Strong coffee with a little lemon juice 
or brandy is often useful in overcoming a malarial chill or a par- 
oxysm of asthma. It is the universal testimony of army officers that 
coffee is indispensable for troops in service to relieve fatigue and 
improve their spirits. 



2l8 STIMULANTS, BEVERAGES, CONDIMENTS 

The stimulating and diuretic effect of coffee is more decided 
when it is taken into an empty stomach. 

The nutrient value of coffee alone is too slight to be considered, 
but the addition of sugar and milk, as in the case of tea, makes it a 
valuable food. It does, however, possess some effect in diminishing 
tissue waste. The very general fondness which exists for the taste 
of coffee makes it a useful means of flavouring many kinds of 
foods for invalids, such as jellies, custards, etc. When the taste 
of milk is objected to, the addition of a very little coffee will often 
overcome the dislike for it. 

Coffee is a useful temporary cardiac stimulant for children suffer- 
ing collapse, but should not be given them as a daily beverage. 

Ill Effects. — Strong black coffee taken after dinner tends to re- 
tard the digestive processes somewhat, and for this reason it should 
be avoided by dyspeptics ; but to persons with sound digestion who, 
perhaps, have eaten rather more food than they need, this influence 
may not prove a disadvantage, and meanwhile its stimulating effect 
may arouse the overtaxed digestive functions. 

Many persons find themselves able to perform much more active 
brain work by the stimulus afforded by drinking coffee and strong 
tea. If one is obliged to work late by night at severe mental 
labour, sleepiness may be avoided by this means. The continuance 
of this practice, however, soon results in forming a coffee or tea 
habit, in which the individual becomes a slave to the beverage and 
feels an imperative need for it at certain hours of the day, when, if 
it cannot be obtained, the system suffers from languor, prostration 
or restlessness, and craving. Exceptionally the coffee habit takes 
the form of eating the coffee beans. By drinking two or three cups 
of strong black coffee at every meal muscular tremors sometimes 
are developed with " nervousness," anxiety, dread of impending ill, 
with palpitation and feeling of precordial oppression, bradycardia 
vertigo, heartburn, dyspepsia, constipation, and insomnia. In such 
cases the symptoms usually promptly subside on suspending or 
restricting the beverage ; but if they have been long continued, the 
use of sedatives may be necessary to control the ill effects. Ex- 
treme cases suggest the condition resulting from some drug habits, 
and there is irritability of the whole nervous system and mental ex- 
citement. Emaciation is common, and pruritus ani has been observed 
by Brown-Sequard. Those who are habituated to immoderate tea 
or coffee drinking do well to stop the habit abruptly in order to 
observe the degree of craving which results and the influence which 
these beverages is acquiring over the system. As an aid to break- 
ing off the coffee habit, " postum " may be used. It is composed 
of cereals and has a flavour which many find agreeable. The pub- 
lished analysis gives 13.13 per cent protein, 66.11 per cent carbo- 
hydrates, 1.60 per cent fat, besides salts and water. In children the 



STIMULANTS AND BEVERAGES 219 

habitual use of coffee gives rise to insomnia, night terrors, nervous- 
ness, and tremor. Acute coffee poisoning differs from the chronic 
form in producing greater excitability, with tendency to delirium 
and tachycardia. 

Quantity Consumed. — In connection with the comments often 
made in regard to the nervousness of temperament which character- 
ises many Americans, it is not without interest to note a fact which 
may stand in the relation of either cause or effect to this condition — 
namely, that the people of the United States consume one third of 
the total coffee produced, which in 1899 amounted to 831,827,063 
pounds, or more than Germany, Austria, Hungary, France, and the 
United Kingdom combined. On the other hand, England and her 
colonies consume one half of the world's output of tea, and the 
United States consumes but one fifth of it. 

Adulteration. — The adulteration of coffee, more particularly 
when it is ground, is so easily accomplished that it affords great 
temptation to unscrupulous dealers. Almost all ground coffee sold 
to the poor is adulterated, but the adulterants are not usually of a 
character to render them injurious to health. Chief among them is 
chicory, which is added both for dilution and for its influence on 
the colour and flavour of the coffee. This substance, however, is 
actually preferred by many persons, and, as it is in no wise injurious, 
it is hardly fair to consider it as an adulterant when its admixture 
with coffee is acknowledged. 

Chicory is prepared from the root of the chicory plant, or wild 
endive, which is roasted and ground. By roasting, an aroma is de- 
veloped, as in the case of the coffee berry. Chicory contains no 
caffeine, but it holds a volatile oil and a bitter principle. Its ad- 
mixture with coffee is detected by bleaching with chlorinated soda, 
which acts promptly on the pigments of chicory, but very slowly 
on those of the natural coffee. 

In France, coffee is frequently flavoured with caramel instead of 
chicory, which is more extensively used in England and the United 
States. 

Coffee is also diluted with various substances, such as peas, beans, 
peanuts, dried sweet potatoes parched, and ground acorns, corncobs, 
or date stones are sometimes used. 

Imitation coffee beans are composed of pellets of roasted wheat 
flour, or sometimes wheat flour and chicory, or even sawdust. Rye, 
corn, and barley are also mingled with wheat for the same purpose. 

Fat globules are present in impure coffee in considerable quan- 
tity. The substitutes for coffee are easily detected by the fact that, 
unlike the true coffee bean, which, unless overroasted, floats after 
roasting, they usually sink to the bottom of a glass of water. 

Colouring matter, like ochre, burnt umber, charcoal, Prussian 
blue, and lead chromate, is added occasionally before the roasting, 



220 STIMULANTS, BEVERAGES, CONDIMENTS 

as well as burned sugar and sirups, in order to affect the appearance 
and colour of the beans. The beans are sometimes polished in 
cylinders, in which they are made to revolve with soapstone. 

Substitutes for Coffee. — A substitute for coffee may be made 
from wheat, rye, or oatmeal, to which butter is added in the propor- 
tion of one part to eight of meal. The butter is melted in a hot iron 
frying pan and the meal is sprinkled over it and briskly stirred with- 
out burning. Thus prepared, the meal resembles roasted coffee, and 
when half an ounce is boiled in a pint of water it makes a beverage 
which is rather agreeable in taste. In Bavaria this substitute for 
coffee is used largely by the peasants, and it is also supplied in some 
charitable institutions in this country. Its use necessitates boiling 
the water, which, if it contains any impurities, is thus rendered harm- 
less. There are several cereal substitutes for coffee sold in open 
market which are advertised as being highly nutritious. A number 
of them were analysed for the United States Department of Agricul- 
ture (Bulletin 122, 1900) by C. F. Langworthy, who says of them: 

" The average cereal coffee infusion had the following percentage 
composition : Water, 98.2 ; protein, 0.2 ; and carbohydrates, 1.4, while 
the fuel value was 30 calories per pound. Skim milk, which is ordi- 
narily considered a rather " thin " beverage, contains 3.5 per cent 
protein, 0.3 per cent fat, 5.15 per cent carbohydrates, and 0.8 per cent 
ash, or almost twenty times as much food material as the average 
of the beverages made from cereal coffee. If made according to 
directions, one would have to drink 4J gallons of an infusion of 
one of them which made an especial claim to high nutritive value 
in order to get as much food as is contained in a quart of skim 
milk." 

Mate, called also Paraguay tea, is manufactured from the dried 
leaves of a plant resembling holly. It is a mildly stimulating bever- 
age which contains theine, but it has no special dietetic advantages 
over tea or coffee. 

Relative Value of Coffee and Tea. — Much argument has been 
expended on the relative digestibility and usefulness of tea and 
coffee, but about all that can be said definitely in regard to the matter 
is, that many persons who can drink tea with impunity are made nerv- 
ous and are kept awake by a similar quantity of coffee, whereas 
there are others who find that coffee aids their digestion while tea 
interferes with it, and that it affects them in every way more agree- 
ably than tea ; and still a third class cannot take either tea or coffee 
without producing indigestion, insomnia, and nervousness. Speak- 
ing generally, coffee is believed in the United States to be 
more digestible and useful than tea, but in other parts of the world, 
especially in England, China, and India, tea is regarded as more 
beneficial than coffee. In equal weight, tea contains more than 
twice as much caffeine or, as it is also called, theine. In this country, 



STIMULANTS AND BEVERAGES 221 

however, it is customary to use about 50 per cent more of coffee 
than of tea to the same quantity of water. 

Coffee is said to irritate the mucous membrane of the stomach 
less than tea when drunk in very large quantities. 

It has a more decided stimulant action than tea upon both the 
force and frequency of the pulse. 

Cocoa 

Cocoa and chocolate are both prepared from the cocoa bean, or 
pulpy seeds of the exotic cacao tree, Theobroma cacao. The major 
portion of the supply consumed in the United States is derived 
from Brazil, the British West Indies, Ecuador, Venezuela, and Dutch 
Guiana. In the United States in 1890 the consumption of choco- 
late amounted to 634,551 pounds, and of cocoa to 993,402 pounds. 

The cacao tree attains a height varying up to twelve metres. 
It blossoms frequently and yields two crops a year of a bright- 
yellow soft fruit. The fruit, which bears some resemblance to a 
small cucumber, contains two or three dozen colourless seeds em- 
bedded in mucilaginous material. When dried in the sunlight, the 
seeds acquire a bright-yellow or brown colour and harden. The 
cocoa starch grains are spherical. 

Preparation. — Cocoa may be either fermented or unfermented. 
The former variety is dried in the sun at once, and the latter is 
kept for some time, in quantity, in a cool, moist place, while fermen- 
tation proceeds. The process of fermentation greatly improves the 
flavour, for the natural acidity and bitter taste of the seeds suc- 
ceeds to a milder, somewhat aromatic, and more agreeable flavour. 

The husks of the cocoa beans are irritant to the alimentary canal, 
and possess little nutrient material. 

The kernels when finely ground constitute " cocoa nibs," from 
which a decoction is made by boiling in water for about two hours, 
and removing the insoluble residue by straining or decanting; but 
the cocoa usually sold in market is made by grinding the kernels 
into a paste, to which starch or sugar is added. If starch has been 
used, the cocoa must be boiled for some minutes, but if diluted 
with sugar it is only necessary to mix it with boiling water or milk. 

The different preparations of cocoa are very numerous, but the 
quantity commonly used for making a single cup of the beverage is 
a heaping teaspoonful or more. 

Composition. — The cocoa beans, after being husked and dried, 
contain fat and theobromine, besides a little albumin, starch, pig- 
ment, and salts. 

The average percentage of the principal ingredients of cocoa 
prepared for a beverage is shown in the following analysis by Stiit- 
zer of a specimen of Holland cocoa : 



222 STIMULANTS, BEVERAGES, CONDIMENTS 

Theobromine x • 73 

Total nitrogenous substances 19.88 

Fat 30.51 

Water .. . 3.83 

Ash 8.30 

Fibre and non-nitrogenous extract 37^48 

Theobromine is the principal alkaloid of cocoa, and is almost 
identical, both chemically and in its physiological effect, with 
caffeine. 

Cacao Butter. — The fat, which is called cacao butter, is the 
nutrient ingredient of most importance. It usually constitutes 50 
per cent of the cocoa bean. It has an agreeable taste and odour, 
and it may be kept indefinitely without change. Because it melts 
readily at low temperatures, it is quickly dissolved in the alimen- 
tary canal, and it is used by itself for making suppositories. 

Uses. — Cocoa is not as digestible as is generally supposed, be- 
cause it leaves a large residue of unabsorbed material from the 
nitrogenous ingredients, and its relative deficiency in starches and 
salts prevents it from being regarded as a " complete " food. What- 
ever nutritive power cocoa possesses depends upon its fat and a 
small percentage of digestible albumin. If the cocoa is roasted by 
too high a temperature, the latter is destroyed. 

The term " soluble cocoa " is erroneous, because neither the fat 
nor much of the albuminous material is truly soluble, and if they 
are removed the food value of the cocoa preparation is much 
impaired. These substances may, however, be reduced to a fine 
state of subdivision and held in suspension, but the cocoa bean 
contains so much fat that it cannot be powdered unless the fat is 
removed by artificial process or diluted with sugar or some form of 
starch. The various powders recommended for invalid diet, and 
which are sold as cocoa or broma, under different proprietary 
names, are made in this manner. They possess rather less strength 
than chocolate, but, on the other hand, because they contain less fat, 
they may be better borne by an enfeebled stomach. The Holland 
cocoa and other preparations are made with the object of obtain- 
ing a digestible cocoa without removal of the fat, which for this pur- 
pose is saponified by the use of sodium and potassium hydrate and 
magnesia. These alkaline substances, while they may be beneficial 
in some forms of dyspepsia, in other cases tend to interfere with 
digestion by neutralising the gastric juice. 

Both cocoa and chocolate differ from tea and coffee in the fact 
that besides making an agreeable and very slightly stimulating 
drink, they contain more food substance. Their actual use for this 
purpose, however, is exaggerated. Cocoa further differs from tea 
and coffee in that the insoluble material is consumed as well as the 
soluble. 



STIMULANTS AND BEVERAGES 227, 

Various cocoa powders, essences, etc., are sold for use by infants, 
a teaspoonful of which may be dissolved in a half pint of hot water. 
Or an infusion of cocoa nibs may be made. Such preparations 
should never be given to very young infants, and, as a rule, it is best 
not to allow their use before the completion of the third year, but 
for young growing children after that age they afford an excellent 
beverage. 

After suspension in hot water cocoa is apt to exhibit a scum of 
fat floating upon the surface of the cup. This may be skimmed off 
on a piece of bread or cracker and eaten in lieu of butter — a practice 
common among the Italians. Cocoa, on account of its large per- 
centage of fat in comparison with starchy ingredients, forms a very 
good addition to a vegetarian diet. 

Adulteration. — The sophistication of cocoa is very easy of ac- 
complishment as well as profitable. It is principally done with sug- 
ars, starches, and fats. Iron salts and other colouring matters are 
often added. These adulterations are fraudulent, but not necessarily 
harmful. 

Chocolate 

Preparation. — Chocolate is manufactured from the husked, dried, 
ground, and fermented cocoa seeds, which are then roasted and 
made into paste and compressed into cakes by moderate pressure. 
To increase the flavour and nutrient power of the cakes more or less 
sugar (but at least 50 per cent) is added, and various flavouring ex- 
tracts, such as vanilla, etc., or spices, are mixed with the paste before 
compressing it. The husks of the seeds are separately sold, and are 
used for adulteration in making cheaper varieties of chocolate. They 
are inferior to the seeds in all their properties. 

Uses. — The value of chocolate as a concentrated food is in part 
derived from the sugar which is added, but it is very nutritious. 
Tested at the Austrian army manoeuvres in 1900, a chocolate ration 
was found to equal five times its weight of beef. Like cocoa, if pure 
and carefully prepared, its ingredients are easily digested and ab- 
sorbed. In cases of dyspepsia and various gastric disorders it forms 
an agreeable and wholesome drink, and it enables the patient to 
take additional nourishment in the form of the milk and sugar mixed 
with it. It is also mildly stimulating and exhilarating to the nerv- 
ous system when exhausted through overwork or worry, and it 
possesses the advantage over tea and coffee that it does not produce 
wakefulness. The free use of chocolate, either eaten or drunk as a 
beverage, constituting what almost might be called a " chocolate 
habit," is not injurious to the nervous system after the manner of 
overindulgence in tea and coffee, but it produces more or less gas- 
tric dyspepsia on account of the large quantity of sugar which it 
already contains or which is added to it when drunk. 



224 STIMULANTS, BEVERAGES, CONDIMENTS 

Chocolate made into compressed cakes forms a convenient port- 
able food that will keep well for a long time, especially when pro- 
tected from drying by a coating of tinfoil or otherwise. These cakes 
contain condensed nutriment which makes them very serviceable 
upon expeditions where provisions can only be carried in limited 
quantity. Condensed milk may be carried to drink with the choco- 
late. The fact that its flavour is so universally liked is an additional 
advantage. 

The chocolate cakes are sometimes prepared with meat extract, 
or when dissolved and drunk, meat powder or raw meat may be 
added to them for phthisical patients or other invalids who require 
concentrated food. 

Chocolate, when not too rich in fat, is a very wholesome food for 
growing children, and is better for them than the more stimulating 
beverages tea and coffee. Its agreeable flavour causes it to be ex- 
tensively used as an ingredient of starchy foods and confections, and 
also to disguise the taste of disagreeable or bitter medicines, such as 
quinine. Many articles of invalid diet, such as cornstarch, farina, 
gelatin, etc., may be made palatable by the addition of chocolate, 
while their nutritive qualities are enhanced. 

Kola 

Composition. — The kola nut is the fruit of a tall tree of the order 
Sterculiacece, growing in the island of Jamaica, on the west coast 
of Africa, East India, and Ceylon. It resembles both coffee and 
chocolate in some of its properties, and its uses are practically the 
same. It contains caffeine, or theine and theobromine, besides a lit- 
tle fat, glucose, dextrin and starch, cellulose, albumins, tannin, mu- 
cilaginous material, a diastatic and a milk-digesting ferment, and 
other substances. 

Uses. — Kola is believed to exercise a restraining influence upon 
tissue waste. It is also mildly stimulating to the heart and nervous 
system, and is diuretic as well as somewhat tonic in its action on the 
stomach. It is said to increase the capacity for endurance of mus- 
cular work. 

Its efficacy has been repeatedly tested by European army sur- 
geons — especially in France and Switzerland — for troops on the 
march, and has been shown to lessen fatigue and diminish the craving 
for both food and drink. 

Kola made into an infusion like coffee, but only one third or one 
half the strength of the latter, forms a smooth, rich, dark-brown fluid 
without sediment or oily scum. It is drunk, like coffee or chocolate, 
with milk and sugar, and has a not unpleasant taste. It is said to be 
well borne by delicate stomachs, and may be prescribed in fevers. 
In large doses it may cause insomnia. As a substitute for food on 



STIMULANTS AND BEVERAGES 225 

forced marches or in mountain climbing it is said by those who 
have tried it to sustain strength for as long as forty hours, and to 
serve better than tea or coffee. 



Alcohol 

Alcohol is a substance produced by a process developed in cer- 
tain sugar-yielding substances (such as grains, molasses, sugar cane, 
etc.) by the action of an organised ferment, the yeast fungus Saccha- 
romyces cerevisice. The chemical changes involved are complex, but 
the chief products are ethyl alcohol and carbon-dioxide gas. A little 
glycerin, succinic acid, and other bodies may be formed. The fungus 
is always floating in the air, so that when saccharine fluids are ex- 
posed to it the fermentation proceeds of itself. Two parts of sugar 
yield approximately one of alcohol. 

Alcoholic drinks may be economically distilled from a great vari- 
ety of cereals, vegetables, and fruits which contain sugar, or sub- 
stances which can be artificially converted into it. There are no 
civilised races, and but few uncivilised or semicivilised people, with 
the exception of the Mohammedans, the northern Eskimos, and one 
or two other tribes mentioned below, who do not practise the distil- 
lation of alcohol in some form or other from the materials most avail- 
able. For example, the spirit fermented from the potato is drunk 
in Lombardy, and that from rice in Japan, and the Fiji Islanders use 
a drink, " kava" made by fermenting with their own saliva the Piper 
mcthysticum. Even the stems of plants are used, as in the case of 
alcoholic beverages made from the sugar cane and the palm. The 
expressed juices of many fruits besides the grape and apple can be 
easily fermented into intoxicating drinks, and when the alcoholic 
fluid obtained lacks flavour it is often re-enforced by some organic 
extract. 

General Discussion of the Value of Alcohol. — The question 
whether alcohol is, properly speaking, a food, or is only to be 
regarded as a beverage and stimulant without power of nutrition, 
has given rise to much warm discussion, and it invariably plays an 
important role among the advocates of teetotalism. A full presen- 
tation of the alcohol question would be foreign to the limits of the 
present work, but the following general propositions comprise the 
belief of many authorities who have devoted careful research to 
this exceedingly important topic : 

t. The use of alcohol in any form is unnecessary for the human 
organism in health. It does not exist as a natural product. The 
very lowest types of man — Australian and many Polynesian sav- 
ages — know nothing of it, and drink only water and fresh fruit juice, 
such as that of the cocoanut, although they speedily acquire a fond- 
ness for alcoholic beverages when given them. 



226 STIMULANTS, BEVERAGES, CONDIMENTS 

2. A large number of persons are undoubtedly better without 
alcohol and may prolong their lives by total abstinence. 

3. The lifelong use of alcohol in moderation as an occasional 
beverage with meals does not necessarily shorten the duration of 
life or induce disease in some persons, while in others it undoubted- 
ly produces gradual and permanent changes, chiefly of a cirrhotic 
character, in the blood vessels and in viscera, such as the liver and 
kidneys. These alterations, which may be slow and subtile in char- 
acter, may not in themselves materially impair the health or cause 
an ultimately fatal result, but they tend to weaken vital organs and 
produce premature senility, so that if the patient acquire any severe 
disease — as, for example, an acute infection, like pneumonia, or a 
chronic one, like tuberculosis — the resistance of the body to the 
invasion of the disease is impaired. There is a prevalent belief that 
these cirrhotic changes are as much due to toxic products of indiges- 
tion caused by alcohol as to the alcohol per se. 

4. There are many persons whose constitutional inheritance is 
such that they should be particularly warned against the use of 
alcohol, and in some such cases, as, for example, among those who 
are subjects of well-marked gouty diathesis, it is better that the use of 
alcohol should be imperatively forbidden. 

5. The abuse of alcoholic stimulation is invariably injurious, 
although the extent to which evil influences become manifest de- 
pends upon the constitution of the individual, in connection with 
the two factors of heredity and environment. 

6. There are a number of diseases in which the temporary use 
of alcohol is of positive service, and there are a number of cases 
in which it becomes a necessity in order to prolong life. 

7. In many cases of malnutrition and malassimilation of food, 
alcohol is itself a food, and its consumption under proper direction 
results in an increase of body weight and strength and improve- 
ment of functional activity. These results are accomplished in part 
through the action of the alcohol as a definite food, and in part 
through its remarkable effect in force production. The latter is due 
to its own direct combustion, by which in chronic diseases and in 
critical acute and exhausting affections it spares that of the tissues 
of the body. 

Although alcohol is such a strong force producer and heat 
generator, its effect in this direction is very soon counterbalanced 
by its stronger influence in lowering the general tone of the nerv- 
ous system and in producing positive degeneration in the tissues. 
In the condition of health more food is usually eaten and more 
force is developed than is actually necessary for the body, and there 
is always a reserve supply of energy on hand which may be util- 
ised for any extraordinary exertion, and hence the constant use of 
alcohol as a food or stimulant in health is both unnecessary and 



STIMULANTS AND BEVERAGES 227 

inadvisable. When alcohol is consumed in health in addition to a 
normal or excessive quantity of solid food by its more ready com- 
bustion it prevents the complete oxidation of the latter and favours 
the accumulation of suboxidised waste products, which are always 
harmful in the system. Excesses in eating are thus doubly aggra- 
vated by the effects of alcohol. It is the almost universal testi- 
mony of army surgeons and the experience of those who, like 
Greely, Stanley, and others, have led long and perilous exploring 
expeditions, involving great fatigue and unusual endurance, that 
muscular overwork and climatic hardships are much better endured 
if alcohol is entirely abstained from. 

It has always been found in armies that when good food was at 
hand the issue of alcohol with the regular ration produced an 
increased percentage of sick days and of incapacity for work. 
Colonel Alfred A. Woodhull, Surgeon, U. S. A., writes me in re- 
gard to this matter : k4 I do not think that any of our medical offi- 
cers would seriously advocate the issue of alcohol as a measure of 
health, but I believe that its habitual use during the civil war was 
prohibited for reasons of discipline, while it still might have been 
occasionally issued as if for health. On the rare occasions when it 
might serve a good purpose as a temporary stimulant after a long 
and wet march, the waggons would be in the rear owing to the same 
conditions that fatigued the men." 

While all this applies to prolonged effort of any kind and to 
conditions where other food can be obtained and assimilated, it 
does not detract from the fact that alcohol is a most helpful food 
and stimulant in emergencies when other food cannot be had or 
when the body is temporarily endangered from acute disease and 
the higher rate of combustion in fever, or from failure to assimilate 
other nourishment. 

Major Woodruff, U. S. A., says : " Spirits can never be used 
in the army as a regular issue ; the practice is thoroughly vicious, 
and was virtually abandoned sixty years ago. On extraordinary oc- 
casions of great fatigue they are allowable in moderation. Under 
such temporary stimulation the men will brace up and perform the 
necessary work of making earthworks, etc., when without it they 
would be too exhausted to do anything. Without stimulation a 
man is not worth much after he has made a forced march of forty 
miles." 

The problem whether the world as a whole is better or worse for 
the existence of alcohol aside from all ethical questions, and viewed 
merely from the scientific standpoint of the influence of alcohol 
upon mortality, is difficult of solution, for to offset the numerous 
cases of fatal alcoholism and the still larger number of cases of dis- 
eases which would not presumably be fatal without the existing 
condition of chronic alcoholic poisoning of the system, are very 



228 STIMULANTS, BEVERAGES, CONDIMENTS 

many cases among both infants and adults in which life is un- 
doubtedly saved by the prompt resort to this food and stimulant 
and its energetic use. So long as man is exposed to hardships and 
conditions arising from improper and deficient food supply as well 
as to the numerous infectious diseases to which he is heir, alcohol 
must still be regarded rather as a blessing than a curse, for there is 
no form of stimulant and food combined or stimulant alone which, 
taken all in all, can be so completely relied upon in cases of emer- 
gency. Alcohol when taken alone will prolong life beyond the 
period at which it would terminate from starvation. 

Physiological Action. — The physiological effects of alcohol may 
be considered under several headings : 

I. Action as a Food. II. Action as a Stimulant to the Nerves 
and Circulation. III. Action upon the Muscular System. IV. Ac- 
tion upon the Body Temperature. V. Action as a Diuretic. VI. 
Action upon Mucous Membranes. VII. Action upon Gastric Di- 
gestion. VIII. Alcohol Absorption — Hypodermic Use. IX. 
Elimination of Alcohol. X. Alcohol Poisoning. XL Alcohol and 
Climate. 

I. Action as a Food. — As a food, alcohol adds to the nutrition of 
the body by its prompt absorption, requiring no preliminary prep- 
aration by the digestive organs, which are therefore not taxed in 
any degree, and it is immediately conveyed in the general circula- 
tion to the liver and other parts of the system. The chemical 
changes involved in the assimilation of this form of hydrocarbon are 
but ill understood. Alcohol, even when digested in very large quan- 
tity, does not reappear to any extent unaltered in the urine, and, 
if not taken in excess, it is not exhaled from the breath, demonstrat- 
ing that its combustion is complete. This combustion results in the 
formation of water and carbon dioxide. The fact that the body 
weight may increase under its use, and that the storage of fat in the 
tissues may be also increased even to an abnormal degree, does not 
absolutely prove that the alcohol itself has entered into their struc- 
ture. Its action may be exerted through modification of oxidation 
processes or by preventing the burning up of other food materials, 
which are thereby enabled to be themselves added to the protoplas- 
mic elements of the body ; yet there is reason to believe that while 
the latter is the chief effect of alcohol as a food, it also may be 
directly stored in the body in the form of some other product, 
although this has been denied by M. Chauveau. Whatever con- 
troversy still exists over the physiological effect of alcohol as a 
food, it is undeniable that in some cases of disease it is clinically 
indispensable. 

Writing of the nutritive value of alcohol in disease, Atwater 
says : 

" What is wanted is a material which will not have to be digested, 



STIMULANTS AND BEVERAGES 229 

can be easily absorbed, is readily oxidised, and will supply the requi- 
site energy. 

" I know of no other material which would seem to meet these 
requirements so naturally and so fully as alcohol. It does not re- 
quire digestion, is absorbed by the stomach, and presumably by the 
intestine, with great ease. Outside of the body it is oxidised very 
readily, within the body it appears to be quickly burned, and it sup- 
plies a large amount of energy." 

Professor Atwater, in 1899, made valuable experiments upon 
man in his respiration calorimeter (described on p. 10), in which 
500 grammes of pure alcohol was given, disguised in a coffee mix- 
ture, and intended to replace a portion of the fats, starches, and 
sugars of ordinary diet. He found that " the alcohol was almost 
completely oxidised. The kinetic energy resulting from that oxida- 
tion agrees very closely with the potential energy of the same amount 
of alcohol as measured by its heat of combustion as determined by 
the bomb calorimeter, and the alcohol served to protect body pro- 
tein and fat from oxidation." 

It is, however, inferior to carbohydrates as a protector of body 
protein from consumption. In some cases it may even increase 
protein consumption, as, for example, when taken in such excess as 
to affect the nervous system and inhibit normal metabolism (At- 
water). 

In referring to the influence of alcohol upon metabolism Bauer 
says : " The increase of albumin suffers thereby no appreciable 
change ; that of fat, on the other hand, is reduced by small quantities 
of alcohol, while by very large doses it is increased at any rate in 
animals. Alcohol also, in consequence of its fat-sparing action, 
behaves in the character of a food." The sugar which is contained 
in considerable quantity in sweet wines, liqueurs, etc., is an addi- 
tional source of nourishment or of fat production. It is a matter of 
common observation that many heavy drinkers are stout. They 
usually indulge more freely in unsweetened liquors or malt liquors 
than in wines, however. Heavy drinkers are often heavy eaters, 
and may be as unable to control their appetite for food as for drink. 
This of course does not apply to cases of alcoholic gastritis, in which, 
temporarily at least, all desire for food may be in abeyance. In a 
general way, alcohol is believed to lessen tissue waste. 

The consumption of alcohol is said to increase the quantity of 
oxygen inspired and lessen the carbonic acid exhaled. 

II. Action as a Stimulant to the Nerves and Circulation. — As 
a stimulant, alcohol acts primarily upon the nervous system and 
the circulation, although it increases the functional activity of many 
organs in the body, and gland secretion may be promoted by its use. 
The influence of alcohol upon the nervous system in moderate doses 
is to quicken the transmission and enhance the effect of nerve cur- 



23O STIMULANTS, BEVERAGES, CONDIMENTS 

rents, accelerating slightly the heart action and, to a lesser degree, 
the respiration, while the mental processes are stimulated in part by 
its direct influence upon the cerebrum, and in part also by the greater 
rapidity of the circulation. 

If alcohol is given in large doses at frequent intervals, it may 
overstimulate the heart, which subsequently becomes exhausted as 
the result of the stimulation. This is sometimes true of the senile 
heart. 

III. Action upon the Muscular System. — Alcohol used within 
physiological limits tends to remove muscular fatigue and to increase 
the force of muscular action. 

In the training of athletes for contests in rowing, sparring, and 
other sports, alcohol is usually absolutely forbidden, and it is believed 
that the breakdown in health which by many athletes is ascribed to 
overwork is not infrequently due to violations in regard to the sim- 
ple physiological laws of the effect of alcohol which the accompany- 
ing features of a " sporting " life tempt them to infringe. The ques- 
tion is well stated by Ringer, who says : " There can be no doubt that 
healthy persons capable of the fullest amount of mental and physical 
exercise without the stimulation of alcohol not only do not require 
it, but are far better without it." But, as he remarks, the statement 
applies to the continued use of strong alcoholic spirits, and not to 
beers and light wines which, in addition to the alcohol, contain 
other ingredients which may be serviceable as food. In the latter 
form of beverages the quantity of alcohol is comparatively small, 
and the constant use of them is found, by the practical experience 
of many persons whose occupations preclude them from abundant 
exercise in the open air in the country, to improve their digestion 
and enable them to sustain various functions of the body which 
would otherwise be impaired by their mode of life. This is espe- 
cially true of elderly people and those who suffer from insomnia and 
retardation of gastric digestion. Experiments to test the sustaining 
power of alcohol were made upon three regiments of the British 
army and reported in 1899. The men were subjected to fatiguing 
exercises. To one regiment a ration of whisky was allowed, to a 
second a ration of malt liquor, and to the third no alcohol. The 
men taking whisky exhibited more energy for about four days than 
either of the other groups, but then became fatigued and weak; 
whereas those taking none steadily gained in endurance, and those 
taking malt liquor showed an intermediate condition. As a result 
of these experiments, the use of liquor was absolutely forbidden in 
Kitchener's Soudanese campaign, which was characterised by re- 
markable immunity from disease in the desert. 

IV. Action upon the Body Temperature. — The physiological 
effect of alcohol upon the body temperature may also be regarded 
as proceeding primarily from its stimulating influence, acting 



STIMULANTS AND BEVERAGES 23 1 

through the vasomotor nerves. In moderate doses, alcohol, by 
quickening the rapidity of the circulation and by dilating the pe- 
ripheral blood vessels, enables more blood to reach the surface of the 
body and to pass through the superficial capillaries in a given time, 
and hence there is a tendency to lower the body temperature. On 
the other hand, the combustion of the alcohol itself within the body 
results in the production of a large number of heat units. The total 
balance of these processes is usually on the side of an absolute reduc- 
tion of the temperature. It is in part for this reason that alcohol is 
of benefit in fevers. 

As a result of an elaborate series of experiments made by 
Reichert to determine the action of alcohol on animal heat func- 
tions, he concludes " that alcohol does not affect the total quantity 
of heat produced ; that more heat is dissipated than produced ; that 
the fall of temperature is due to the excess of dissipation, and is 
in direct proportion ; and that in all likelihood alcohol, by under- 
going oxidation, yields energy in the form of heat, thus conserving 
the tissues and acting as a food." 

V. Action as a Diuretic. — Alcohol in some persons, although 
not in all, is a very strong diuretic, and its effect depends largely 
upon the variety of the beverage used. For some persons gin has 
a much more decided diuretic action than other strong liquors, such 
as rum or brandy, and in many beer possesses a diuretic action 
which indicates a special stimulating effect upon the total quantity 
of urine excreted beyond that produced by a similar bulk of water, 
but the total of urea, sulphates, and phosphates eliminated is dimin- 
ished. Chittenden found that uric-acid excretion is doubled. As a 
general rule, alcohol which is moderately diluted, and which is taken 
upon an empty stomach, is much more promptly absorbed and pos- 
sesses a stronger diuretic action than when taken with food or when 
given in a concentrated form. 

VI. Action on Mucous Membranes. — Strong alcohol is astrin- 
gent to mucous surfaces, and it is sometimes used diluted with equal 
parts of water as a gargle for sore throat. Claret, which also con- 
tains tannin, may be employed in this way. 

If taken in too large quantity or too strong, the astringent effect 
upon the stomach is highly irritating, causing local congestion, and 
even inflammation upon the mucous coat, which becomes covered 
with tenacious mucus. The tongue soon becomes coated, and the 
appetite is destroyed as well as the secreting power of the gastric 
glands. 

VII. Action upon Gastric Digestion. — Taken with food in the 
stomach, alcohol in small quantities, not exceeding the equivalent 
of half an ounce of the pure substance, given in the form of any 
alcoholic beverage, does not materially affect the action of the 
gastric juice. In larger quantities, or if the gastric juice itself is 

17 



232 



STIMULANTS, BEVERAGES, CONDIMENTS 



feeble, alcohol precipitates pepsin, coagulates the albuminous ma- 
terials of the food, and greatly retards if it does not altogether de- 
stroy gastric digestion. On the other hand, while not interfering 
with the action of the gastric juice, alcohol may stimulate its secre- 
tion so that, as Moleschott says, " a glass or two of good old wine 
increases the quantity of gastric juice, which performs mainly the 
digestion of albuminous foods." 

Some interesting experiments are reported by Roberts (Lec- 
tures on Dietetics and Dyspepsia) upon the effect of malt liquors 
on gastric digestion. They were conducted as follows : By add- 
ing together 2 grammes of dried beef-fibre, 0.15 c. c. of hydro- 
chloric acid, 1 c. c. of glycerin extract of pepsin, and varying 
quantities of malt liquors, with water up to 100 c. c. The result 
is tabulated : 



Proportion of Malt Liquors con- 
tained in the Digesting Mix- 
ture. 



TIME IN WHICH DIGESTION WAS COMPLETED. 
(NORMAL, IOO MINUTES.) 



Burton ale. 



Light English 
table beer. 



Lager beer. 



10 per cent 
20 " " 
40 " 
60 " " 



115 minutes. 
140 " 
200 " 
Embarrassed. 



100 minutes. 
115 " 
140 " 
180 



100 minutes. 

115 

140 " 

180 



In considering the relation of alcohol to other foods, the fact 
should be emphasised that monotony of diet with bad cooking of 
coarse, tasteless food, especially when associated with overwork, may 
be a potent factor in establishing a liking for liquors among the 
poor. In the United States, among the poorer classes the art of 
varying the diet and of serving food in an agreeable and properly 
seasoned manner is but imperfectly understood, and the statement 
is confidently made by Williams, who has given years of personal 
attention to the matter, that " the raw material of the dietary of the 
French and Italians is more inferior than that of the English, but a 
far better result is obtained by better cookery, and the same un- 
favourable comparison can undoubtedly be made with the poorer 
classes in America." The Italians have the art of making compara- 
tively tasteless food, such as macaroni, into very savoury and nutri- 
tious dishes. Osier expresses the opinion that more ill arises from 
abuses of eating than of drinking, especially in America. 

VIII. Alcohol Absorption. — Alcohol is highly diffusible, and is 
promptly absorbed from mucous surfaces as well as from subcu- 
taneous tissue. 

Its effect is always more immediate when taken into an empty 
stomach. It is then rapidly absorbed, and its influence is exerted 
suddenly. When there is food in the stomach, some of the alcohol 
is temporarily taken up by it like water by a sponge, its absorption 



STIMULANTS AND BEVERAGES 233 

is delayed, and, since its elimination is quite rapid, the system is less 
likely to become overcharged with it. 

Alcohol is well absorbed from the rectum, and to patients who 
for any reason are unable to retain it in the stomach it may be 
given in this manner. For this purpose it is best to use spirits 
diluted with from one to four parts of water, and an ounce of whisky 
or brandy should be given for a dose. 

Hypodermic Use. — Very little alcohol can be made to pass into the 
body by rubbing it upon the skin, although it is a diffusible sub- 
stance, but it is very promptly absorbed when injected hypodermic- 
ally, and where its immediate stimulating effect is required it can 
be thus sooner obtained. Owing to the local irritant action of 
alcohol, not over a drachm or two should be placed beneath the 
skin at any one point, for it is often quite painful. The surface 
should be rubbed to promote its absorption. In emergency, two 
or three ounces may be quickly given in this way in divided doses. 

IX. Elimination. — The questions of what intermediate products 
may be formed by the splitting up of alcohol in the blood or tissues, 
of the influence of the combustion of alcohol, and of the combustion 
of the tissues themselves, involve great difficulties in the way of 
chemical analysis, and the liabilities to error are considerable. It 
may be regarded as proved, however, that when taken in moderation 
alcohol is completely consumed within the body, or so completely 
that a mere trace escapes in the urine and perspiration, and a little 
more in the exhaled air. If the dosage of alcohol is very much 
increased, however, its elimination, unaltered, becomes proportion- 
ately active, although it is still consumed in large amount in the body. 
The excretion of C0 2 by the lungs is lessened. 

Alcohol is believed to prevent the elimination of tissue waste 
under some conditions, and, in spite of the fact that it acts as a 
diuretic, it may lessen the excretion of urea and uric acid. 

X. Alcohol Poisoning. — This topic will be more conveniently dis- 
cussed with the treatment under the heading Alcoholism. 

XL Alcohol and Climate. — It is an established fact that climatic 
conditions exercise an important influence upon the degree to which 
alcohol influences the system. Many persons find that they can 
drink more spirits and wine during a prolonged residence in a cli- 
mate like that of England without apparent ill effect than they can 
in the more stimulating and bracing climate with greater extremes of 
temperature which exists in many parts of the United States. If men 
are to be exposed to cold and hardship for a considerable period of 
time it is highly unwise for them to indulge freely in alcoholic drinks 
on account of the rapid fall in the body temperature, which is pro- 
moted by the external cold when alcohol relaxes the capillaries. 
In illustration of this principle, a story is told of a party of engi- 
neers who were lost during the winter in the Rocky Mountains, 



234 STIMULANTS, BEVERAGES, CONDIMENTS 

where, after prolonged exposure to cold and hardship, they were one 
night obliged to sleep without shelter with the thermometer below 
zero. They had whisky with them and but little food ; some of the 
party drank heavily, others drank in moderation, and a few of the 
wiser took no alcohol at all. In the morning the latter awoke, cold 
but refreshed by the night's rest, while others Avho drank in modera- 
tion were very much more uncomfortable and had suffered far more 
from the exposure, and one or two of those who had drunk freely 
were frozen to death. 

Otto Snell interrogated sixty expert mountain-climbers, and only 
five declared that liquor was not injurious if taken before or during 
their exertions. 

In the arctic expeditions of Greely, De Long, and others, al- 
though pure alcohol was carried for cooking purposes, very stringent 
regulations had to be enforced to prevent the men from drinking 
alcoholic beverages, which were only kept for emergencies and sick- 
ness. The northern Eskimos are ignorant of such drinks, having 
nothing which they can ferment to produce them. On the other 
hand, the natives of tropical climates are in the habit of distilling 
many varieties of alcoholic drink from the fermentation of vege- 
table food. 

Clinical Uses of Alcohol 

i. Use as a Tonic. — Very moderate doses of alcohol increase the 
flow of gastric juice, and for this reason it may be employed with 
advantage in cases such as the following : i. By those whose nervous 
system is readily overtaxed and who when fatigued or worried lose 
all appetite. 2. By persons of sedentary habits who have greatly 
enfeebled digestions. 3. In protracted convalescence from severe 
forms of acute diseases. For any of these patients a mild cocktail, 
a little whisky and water, or a glass of simple bitters may be 
ordered to be taken directly before meals in order to improve the 
" tone " of the stomach. In all cases care should be exercised, espe- 
cially among persons who may possibly inherit the alcoholic habit, 
that the beverage be not prescribed too often, for sometimes cases of 
chronic alcoholism originate among persons who begin by resorting 
to this food and stimulant to tide them over emergencies such as the 
above, and who find when the emergency is passed that they are 
unable to relinquish the acquired fondness for the drink. When 
troops have been exposed to exhausting service in a hot, humid 
atmosphere such as that of some of the Philippine Islands they 
suffer greatly from nervous exhaustion and insomnia. In such 
cases, besides an ample ration, the use of from two to four ounces 
of whisky or other liquor per diem, greatly diluted, appears to be of 
value as a tonic and digestible food. Writing of this matter, Major 
Charles E. Woodruff says : " Experience has demonstrated that in 



STIMULANTS AND BEVERAGES 2y y 

a hot climate the moderate use of intoxicating drink is essential to 
continued health and efficiency." 

2. Use as a Vascular and Cardiac Stimulant. — If there is general 
arterial relaxation from debilitating disease, the use of alcohol in 
proper quantities contracts the vessels and improves the firmness 
and quality of the pulse to a remarkable degree. Alcohol undoubt- 
edly can be given the first place among the cardiac stimulants, for 
its combined action in strengthening the heart and regulating the 
calibre of the blood vessels is most useful. For this purpose it is 
best to use strong liquors, such as brandy or whisky, which vary but 
little in composition, and which may be diluted according to need. 
In all cases of sudden heart failure occasioned by shock, violent hem- 
orrhages, either internal or external, fainting, etc., it is best to give 
alcohol in the form of diluted spirits. 

It is an interesting fact that the mere mechanical action of deglu- 
tition stimulates the heart action and increases the rate of pulse beats 
by fifteen or twenty in the minute. Stimulants sipped slowly by re- 
peated acts of swallowing for this reason alone may have a greater 
effect than the same quantity of fluid drunk all at once. In extreme 
emergencies, whether the patient is able to swallow or not — as, for 
example, in shock from prolonged anaesthesia, or from the use of 
anaesthetics which are not well tolerated, and in an urgent case when 
the alcohol is given by hypodermic injection — it may be used undi- 
luted. Its influence in these conditions is almost immediate, and the 
stimulation of the pulse may be appreciated in two or three minutes. 
A little more time is required for the full effect if the stimulant is 
given by the stomach or rectum. The benefit of alcohol is further 
shown by the tongue and skin becoming more moist, by the slowing 
of the pulse, and by the breathing becoming more tranquil. Since 
alcohol regulates arterial tone and brings the pulse to a nearer nor- 
mal standard, the volume of the pulse is not so important a consider- 
ation as is its compressibility as a factor in estimating the value of 
alcohol in a given case. The very soft pulse of considerable volume 
may diminish in volume under the use of alcohol, but it becomes 
firmer and of better character, showing an improvement in the 
arterial tone. The rules for observing the effect of alcohol may be 
definitely applied in almost every case, and the dosage can be regu- 
lated accordingly. In acute diseases, such as pneumonia, in which 
the emergency of cardiac failure or great prostration may be fairly 
anticipated, it is often better to withhold alcohol until there are defi- 
nite indications for its use than it is to prescribe it in a routine man- 
ner at the commencement of the disease ; its effect when actually 
needed is enhanced if it has not been already given for too long a 
time. For persons with feeble constitutions, however, and for aged 
people it may be necessary to commence the use of alcohol at an 
earlier period. In urgent cases full doses, such as an ounce an hour, 



23^ STIMULANTS, BEVERAGES, CONDIMENTS 

may become necessary for a few times, and the quantity and inter- 
vals for its administration may then be gradually reduced. Usually 
when the stimulating and supporting influence of alcohol is urgently 
needed it is better to give it in quite frequent doses and in moderate 
quantity than in large amount infrequently. The stimulation is then 
more uniform and constant, and the digestive organs are less likely 
to be deranged. 

3. Use in Nervous Diseases. — Alcohol is of service for many 
forms of diseases of the nervous system. Neuralgic pains are some- 
times allayed by the use of alcoholic drinks which contain volatile 
ethers, but they should be prescribed with care. In any neuralgic 
or nervous affections, such as hysteria, which are more or less 
chronic, it is well to observe that many of the so-called elixirs, nerve 
tonics, etc., which are recommended for cases of this nature, and 
especially for treatment of nervous prostration, contain a large per- 
centage of alcohol, and their constant and indiscriminate use is liable 
to establish permanent alcoholism. In the stomach alcohol may act 
as an anaesthetic in cases of irritant nervous dyspepsia. 

4. Use in Fevers. — The whole question of the employment of 
alcohol in fevers is obviously of grave importance. 

The value of alcohol in the treatment of fevers is now universally 
recognised, and its beneficial effect is manifested in two ways : first, 
upon the vital functions of the nervous system, circulation, and heat 
regulation ; and, secondly, in sparing the tissues from too rapid com- 
bustion and wasting by furnishing fuel in their stead. In fever the 
increased nitrogenous waste is evidenced by the greater elimination 
of urea from the kidneys, while the quantity of urine and perspira- 
tion are lessened. The use of alcohol meets all indications by 
lessening the production of nitrogenous waste, by acting as a diu- 
retic, and by regulating the peripheral blood pressure and increasing 
the perspiration. To accomplish these results, usually six or eight 
ounces in the twenty-four hours, and often much more, must be 
given. 

As a mere antipyretic the influence of alcohol is less striking 
than that of many special remedies which have the power of reduc- 
ing the body temperature, but it has the decided advanta'ge over 
most of these remedies that its proper use is accompanied by stimu- 
lation rather than depression of the heart action. 

It may be regarded as a general rule that when given in large 
quantities if the odour of alcohol is not present in the breath several 
hours after it has been ingested, and if the pulse is slowed and deli- 
rium is reduced under its use, the amount taken is clearly being 
oxidised as a food and is doing good. On the other hand, if the 
odour persists in the breath and the pulse is not improved, or the 
patient becomes more delirious, it indicates that too much alcohol 
is being given, and the dosage should be accordingly reduced. 



STIMULANTS AND BEVERAGES 237 

The effect of alcohol in fevers is shown by the fact that in health, 
when drunk in large quantities, it excites gastric catarrh and occa- 
sions dyspepsia, whereas a similar amount taken in the height of an 
acute fever may be very beneficial. 

It must not be inferred from the foregoing statements that alco- 
hol should be given at once in fever, or that it should be given in 
every fever. There are many cases in which it is contraindicated. 
Such are of sthenic type and of short duration. There are others in 
which it is a mistake to give it too early, and its use should be post- 
poned until the conditions are present of prostration and nervous 
exhaustion. There are still other cases in which it should be pre- 
scribed at once, as, for example, in pneumonia in feeble or elderly 
subjects. 

The general indications for the use of alcohol as a food in con- 
tinued fevers or for an increase of the quantity already being given 
are found in the predominance of one or more of the following symp- 
toms : Increased weakness or faintness, low muttering delirium con- 
tinued even when the patient is undisturbed, tremor of the tongue 
and hands, great dryness of the tongue, extreme feebleness of the 
voice, irregularities in the respiration and pulse, enfeebled or irregu- 
lar heart action, and absence of either of the cardiac sounds. 

There is a tendency at the present time to abandon excessive 
dosage of alcohol in severe acute febrile infectious diseases, such 
as pneumonia and typhoid fever, in which it was formerly given 
at the rate of an ounce an hour or twenty-four ounces per diem, 
for it is found that other stimulants, such as digitalis, strychnine, 
caffeine, etc., make it possible to use less spirits. A full discussion 
of this topic will be found under the heading Dietetic Treatment of 
Fever. 

In the treatment of convalescence, when patients are able to 
digest and assimilate more and more food, less alcohol is required. 

Proper Time for giving Alcoholic Beverages. — Whenever an alco- 
holic beverage is prescribed by the physician, the time at which it 
is to be given should be explicitly stated, and there should be super- 
vision over the quantity used, depending upon the influence upon 
appetite and activity of digestion. When needed as a tonic, the 
beverage should be given either immediately before or in connection 
with meals, in order that its effect may be modified by that of other 
foods. There is less fear of establishing a craving for drink if this 
rule be observed. It is the habit of drinking between meals without 
definite purpose which is particularly dangerous. 

In some cases of neurasthenia, anaemia, etc., it may be advisable 
to recommend a glass of claret or sherry between the principal meals, 
in the middle of the morning or afternoon, but even then it should 
be taken with some article of light and easily digestible food, such 
as a. biscuit or sandwich. The fact that moderate doses of alcohol 



238 STIMULANTS, BEVERAGES, CONDIMENTS 

improve the functional activity of the stomach affords an oppor- 
tunity for the better digestion of food given in connection with alco- 
hol, which should not be lost by giving the latter alone. 

There are some patients having chronic atonic dyspesia and per- 
sons with but limited nervous energy for whom it is better to pre- 
scribe alcohol half an hour or more before eating in order that its 
stimulating influence may be felt in the system before the nervous 
forces are called upon for digestive functions. 

Selection of the Proper Form of Alcoholic Beverage. — In all 
severe cases in prescribing alcohol it is a rule that the stomach is 
much less likely to be upset by adhering to a single form of bever- 
age than by making frequent changes. Persons having robust phy- 
siques may be able to assimilate several kinds of wines, including 
champagne, at dinner, followed by liquors and brandy ; but these 
beverages, if taken in such variety without food, will almost in- 
variably derange the stomach, and the unpleasant after-effects which 
characterise even moderate overindulgence in this respect are usu- 
ally more decided if a variety of beverages have been used than if 
only one kind has been taken. The combination of whisky and 
beer or strong liquors and champagne will promptly disagree with 
many persons who could take either form of alcohol alone with 
impunity. In fever the stomach is always temporarily enfeebled, 
and the importance of adhering to one simple form of alcoholic 
beverage is emphasised. It may be changed from time to time in 
conformity with the taste of the patient, but mixtures of beverages 
should never be given. 

With persons who are predisposed to irritating coughs the use 
of malt liquors sometimes increases the difficulty, whereas strong 
liquors and wines may prove beneficial. Beer, ale, porter, stout, etc., 
cannot be drunk by some persons without producing a subsequent 
feeling of lassitude and drowsiness with headache and suffusion of 
the face, and yet diluted spirits may be well borne. Some persons 
find that sherry produces acid dyspepsia, and others find that dif- 
ferent sweet wines, such as port, similarly disagree, and in others 
again they excite attacks of gout. When porter, ale, or stout do 
not derange the stomach, they may be advantageously used by those 
who suffer from exhausting discharges or by women who are weak- 
ened by prolonged suckling. Alcohol should be emphatically for- 
bidden in all forms of gonorrhoea and syphilis, and a single infringe- 
ment of this rule may often aggravate the complaint. Some 
clinicians prefer the use of wines which are well charged with vola- 
tile compound ethers as a stimulant for enfeebled heart action and 
weak digestion. The use of beer as a beverage for fevers is more 
common in Continental Europe than in the United States. If there 
is no tendency to flatulent dyspepsia, it may sometimes be used with 
advantage in such cases, when it will slake the thirst which is not 



STIMULANTS AND BEVERAGES 



239 



quenched by other drinks. Passing fashion to some extent influ- 
ences the variety of alcoholic beverage consumed, as illustrated by 
the fact that in this country the annual importation of Scotch whisky 
has lately risen from 30,000 to 100,000 gallons for a single firm. 
Rum and port are much less drunk than formerly. 

As a preventive of drunkenness and the evils of chronic alcohol- 
ism, the introduction of the milder malt liquors into this country to 
partially supersede the use of strong spirits has proved a decided 
advantage. The total annual consumption of all alcoholic beverages 
in the United States exceeds one billion gallons. In 1870 the per 
capita consumption of distilled liquors was 2.07 gallons, and twenty- 
five years later this fell to 1.12 gallons, whereas during the same 
period the consumption of malt liquors rose from 5.31 to 14.95 g^l- 
Ions. The consumption of wines has remained at about 0.32 gallon. 

The annual per capita consumption of alcoholic beverages in 1900 
in several countries as compared with the United States is estimated 
in gallons as follows : 



England 

France 

Germany 
United States. 



Beer. 



30.3I 

5-1 
25-5 
12.3 



Wine. 



0.39 

21.8 

i-34 
0.44 



Spirits. 



I.02 
I.84 
I.84 
O.84 



Italy, France, and Spain grow two thirds of the world's wine, 
and in France the annual consumption of spirits is only 3.80 litres 
per capita. 

A Committee of Fifty for the Investigation of the Liquor Prob- 
lem was organised in this country in 1893. The committee con- 
sists of eminent jurists, physicians, physiologists, philanthropists, 
and others, and their object is to collect and study impartial scien- 
tific data regarding the consumption of liquor which shall furnish 
a reliable basis for controlling future legislation in regard to the 
liquor problem and influence public opinion in regard to its evils. 
In co-operation with this investigation, Prof. Henry W. Farnam 
states (in T899) tnat " tne native-born Americans fall midway, being, 
as a rule, more addicted to liquor than the Germans and Scandi- 
navians, but less so than the English, Canadians, and Scotch. The 
coloured race, however, as compared with the white, shows a good 
record." 

Malt Liquors 
beer 

The lager-beer industry was introduced into the United States 
about the year 1842. 

Composition. — Beer contains alcohol in strength varying between 
3 and 8 volumes per cent (sometimes even 10 per cent). Besides 



240 STIMULANTS, BEVERAGES, CONDIMENTS 

this alcohol and much water, beer contains a variety of ingredients, 
such as bitter and resinous extractives from hops, sugar, dextrin, 
albuminates, glycerin, free acids, and ash — the latter only as a trace. 
The sugar of beer is fattening, and the bitter matter is more or less 
of a stomachic tonic. 

By process of manufacture much beer is made to contain only 
water, alcohol, and bitter principles. Hop extracts possess a nar- 
cotic influence, and hence beer may give rise to drowsiness, whereas 
other alcoholic beverages — like champagne or whisky — prove enliv- 
ening. This effect is, however, quite variable. 

Beer produces biliousness in persons of weak digestion. It is 
sometimes called " fluid bread," but the expression conveys a wholly 
exaggerated idea of its food value, although it is certainly fattening 
when drunk in large quantity. 

Beer Brewing. — Malt is the name given to any germinating 
cereal, but to prepare it for beer brewing, malt is made from barley 
grains as follows : The grain is steeped in water at a temperature 
which causes germination and the development of diastase. It is 
next couched and " floored," during which process germination con- 
tinues, and it is finally kiln-dried. 

Brewing of beer is accomplished as follows : The prepared bar- 
ley malt is first cleaned by screening, sifting, and blowing, is crushed 
and then " mashed " or infused with water in large tubs at a proper 
temperature. This process extracts the existing sugar and dextrin 
and aids in converting the residue of starch into maltose and dex- 
trin. The " wort " thus formed is a solution of diastase, dextrin, 
sugar, proteids, and salts. It is drawn off, and the residue of grain 
is washed with hot water by a process called " sparging," which 
extracts any remaining useful material. The wort is run into cop- 
per kettles and boiled for about four hours. During the last hour 
hops are poured in. The boiling concentrates the wort, extracts 
the hop essence or lupulin with tannin, causes coagulation and pre- 
cipitation of any albuminous substance, and finally it checks further 
fermentation for the time being. The wort is next cooled and yeast 
is added in the proportion of about a pound to the barrel. The 
yeast sets up a new fermentation, which converts the saccharine 
substances into alcohol and carbon-dioxide gas. This fermentation 
is retarded by continued application of cold. When it is concluded, 
the beer is drawn into settling tuns, and then into casks, where it is 
stored from five to eight months, after which it is ready for bottling. 
While resting in the casks the beer is subjected to " fining " — i. e., 
beech-tree shavings are added to it, to collect any floating solid par- 
ticles. This process allows so much carbonic acid to escape that a 
second fermentation is sometimes set up by adding new beer to the 
old in the proportion of I to 5. 

Beer which is kept long fermenting increases in alcohol and 



STIMULANTS AND BEVERAGES 241 

diminishes in extractives. Its natural intensity of colour varies 
with the method of drying the malt, and increases with long 
boiling. 

White beer is brewed from wheat instead of rye. It is less clear 
than rye beer, paler, and more frothy and sour. 

The low Bavarian beer is fermented by a variety of saccharo- 
myces, which acts at a temperature of 6° to 8° C. 

Certain varieties of saccharomyces, acting at different tem- 
peratures, set up undesirable fermentation in both beer and wine, 
making them sour, and developing peculiar odours. 

Ale. — Ale is made from pale malt by processes resembling the 
brewing of beer. It contains from 3 to 6 per cent of alcohol. 
Strongly alcoholic ales are less used than formerly, having been 
largely supplanted by the lighter varieties and by beer. The amount 
of hops used determines the bitterness of the ale, and their aromatic 
bitter principles furnish the peculiar flavour. Bitter ale has been so 
far fermented as to contain but little sugar. 

Porter. — Porter is made from pale malt with the addition of high 
dried malt, which gives it colour and flavour. It contains about 6 
per cent of alcohol, and is regarded as more digestible than ale of the 
same alcoholic strength (Pavy). Both ale and porter contain sugar 
and acid, but these substances are present in less degree in malt 
liquors than in wines. 

Stout. — Stout is similar to porter, but is characterised by a pre- 
ponderance of extractives. 

The stronger malt liquors, such as porter, stout, and heavy ales, 
are nutritive and fattening. 

All stale, flat malt liquors without a " head " are apt to nauseate 
and prove unwholesome. 

WINE 

Composition. — Wine made from the expressed juice of different 
varieties of the grape consists of an alcoholic solution varying in 
strength from 6 to 25 volumes per cent, and containing flavouring 
and other substances. 

The maximum normal percentage of alcohol which fermenting 
grapes are capable of developing is not above 15 per cent, but alco- 
hol is often added to equal 18 or 25 per cent or more. 

The pulp of the grape furnishes sugar for fermentation of alcohol, 
and also organic acids or their salts, such as citrates, malates, and 
tartrates. The stones or seeds furnish essential oils, some of which 
give the " bouquet " of volatile ethers, and the skins and stems fur- 
nish pigments and tannin. The latter is preservative ; it precipitates 
albuminous substances and prevents mouldiness. The chief pigment 
of wines is primarily of a blue colour, but it is reddened, like litmus, 
by free acid, more or less of which is always present. 



242 STIMULANTS, BEVERAGES, CONDIMENTS 

The fermentation of wines is caused by germs, which exist upon 
the stems or skins of the grapes. 

Besides water, sugar, alcohol, volatile ethers, and carbonic acid 
are added in the manufacture of the different kinds of wine. 

Leoser gives the following list of minor substances, traces of 
which are more or less constantly present in wines : " Gelatin, gum, 
fat, wax, albumin, gluten, tartaric acid, potassic tartrate, racemic 
acid, malic acid, calcic malate, oxide of manganese, oxide of iron, 
potassium sulphate, sodium chloride, calcium phosphate, magnesia, 
silicic acid, tannic acid." 

The composition of the subtle substances which impart the fla- 
vour and aroma or bouquet to different wines is unknown. Most 
of these substances develop during fermentation, but a few grapes, 
such as the Muscatel, yield their own aroma to the wine. 

According to Konig, the average percentage composition of 
grape must is water, 74.49 ; sugar, 19.71 ; nitrogenous material, 0.28 ; 
non-nitrogenous material, 4.48 ; ash, 0.40 ; acid, 0.64. 

The sugar fluctuates sometimes as much as 24 per cent and the 
acid 1.2 per cent, and these substances usually stand in inverse pro- 
portion to each other. 

General Properties. — The perfected wine has the properties of 
colour, " body " or substance, and flavour, aroma, bouquet, or 
" fruitiness." Different wines are valued for their astringency (tan- 
nin), sweetness (grape sugar), strength (alcohol), acidity (organic 
acids), colour or sparkle, flavour, and ability to stimulate the appetite 
and digestion. 

Fermentation. — Wines are both naturally and artificially ferment- 
ed, and many varieties are re-enforced by flavouring extracts and 
fortified by addition of alcohol. The latter method has the twofold 
effect of adding to their strength and of preserving them from further 
fermentation, and hence is used especially for the wines of the Cape, 
Madeira, and Portugal. In the cooler climate of France, Germany, 
and Hungary fermentation proceeds more slowly and fortification is 
less necessary, for the wines of these countries are drier, less fruity, 
and require less time to mature. They also have stronger bouquet, 
because they possess more acid, which combines with alcohol to fur- 
nish the aroma (Pavy). 

Sugar. — The quantity of sugar present in wines varies consider- 
ably. It is sometimes almost completely eliminated by fermentation 
into alcohol, or it may be added in excess to make the natural flavour 
sweeter. 

Flavour and Bouquet. — Some Greek wines have a peculiar flavour, 
the liking for which is an acquired taste. This flavour is derived 
from rosin contained in the wood of casks used for preserving the 
wines, which induces chemical changes. 

The Hungarian wines have agreeable fruitiness, but they are not 



STIMULANTS AND BEVERAGES 243 

so completely ripened as French wines, and are hence likely to turn 
sour when transported. 

Both glucose and saccharose can be oxidised into acids instead 
of fermenting to alcohol, and when this process occurs extensively 
in a wine it becomes sour, like vinegar, and is unfit for consump- 
tion. 

In general the flavour and bouquet of a wine depend upon (1) the 
nature of the soil in which the grape is grown, (2) the climate and 
temperature, (3) the quality of the grape, (4) the use of but a single 
variety of grape for a given wine, (5) the ripeness of the grape, (6) 
the duration of fermentation, (7) the addition or subtraction of ma- 
terial by the art of the wine grower, (8) the age of the wine. 

In vineyards where the best wines are made the grapes are tested 
from day to day to determine the right time to pick the vines, for 
the quantity of sugar and acid present depend upon the degree of 
ripening and influence the flavour of the wine. 

White Wines. — White wine is made from grapes of any colour, 
the greatest care being taken not to macerate the berries in express- 
ing the juice, and to allow no coloured juice to flow. As a rule, 
however, the better class of white wines is made from selected white 
grapes, which are crushed with their skins. The mass is left for 
several days, so that the skins may impart what little soluble matter 
they contain to the pulp. The juice is then obtained by further 
pressure and allowed to ferment. The crushing of grapes was for- 
merly done by the feet of men who trampled upon them, but several 
lives were lost by carbonic-acid gas poisoning, and the process is 
now generally conducted by machinery. 

After several months, or longer, the ferment and the salts which 
are insoluble settle in a sediment called lees, and the supernatant 
fluid is carefully drawn off and casked or bottled. 

During the first year or so of storage some wines are recasked 
several times, for they continue to deposit lees on the bottom and 
sides of the cask, consisting mainly of " argol," an acid salt from 
which cream of tartar may be prepared. 

When fermentation has proceeded long enough it is stopped, 
according to the nature of the wine, by the addition of alcohol or 
strong sugar solution, or if left to continue after the wine is stored, 
the sugar and extractives very gradually disappear, and alcohol con- 
tinues to develop. 

Hence, if a wine can be bottled early without being too green 
or immature it is sometimes a decided advantage, for more of the 
aroma and flavour may be thus retained. 

In other cases wines should remain in the casks for from one 
to four years before bottling — the more delicate varieties being kept 
the longest — for certain changes depend upon the size and nature of 
the containing receptacle, which are checked by bottling. Pavy 



244 STIMULANTS, BEVERAGES, CONDIMENTS 

says : " By keeping in a cask, wine increases in alcoholic strength. 
This is to be accounted for by wood being more easily penetrated 
by water than by alcohol. Thus it happens that water is lost by 
evaporation from the outside of the cask in larger quantity than 
the alcohol, and the wine is left in a more concentrated con- 
dition." 

White wines are produced in more variety than red wines. On 
the average they contain from 9 to 12 per cent of alcohol, from 
0.30 to 0.50 per cent of sugar, and about 0.50 per cent of acid. 

Red Wines. — In making red wine dark grapes are used, and 
both skins and stones are left to ferment with the pulp, to which 
they furnish tannin, pigment, and extractives. 

Red wines, on the average, contain from 8.5 to 11 per cent of 
alcohol, 0.55 to 0.65 per cent of acid, and 0.15 to 0.20 per cent of 
tannin and pigment. The red wines are, as a rule, more easily di- 
gested than white, and are more nutritive. 

The following practical statements are quoted from Leoser : 

" Bottled red wines that are rich in tannic acid, like port, for 
instance, deposit a sediment and grow lighter in colour. Those 
that contain less tannic acid generally grow darker. The cause of 
this is a gradual diminution in the quantity of free acid in the wine. 
The effect of this acid is to turn the colouring matter red, and as it 
diminishes, therefore, the wine grows darker or more purple." 

Red wine (claret) is often drunk diluted with Vichy, when " the 
potassium carbonate of the water saturates the free acid of the wine, 
and so destroys the red colour and permits it to become darker, 
while the action of the alkali upon the colouring matter gives it a 
cloudy appearance." 

The deeper the colour the rougher is the flavour of the wine in 
most cases. 

" If two wines of equal alcoholic strength be taken it will be 
found that equal doses of each will produce their effect much more 
quickly in the case of the white wine than in that of the red. The 
reason of this is that the astringent action of the tannic acid retards 
the effect of the alcohol upon the organism. It may be that this 
indicates in a general way the superiority of white wines as stimu- 
lants and red wines as tonics." 

Various substances are used for " fining " — that is, to clarify wine 
— such as cream, milk, blood, solutions of egg albumin, gelatin, 
isinglass, nutgalls, lime, etc. Their effect is largely mechanical, but 
the alkalies neutralise part of the acids. 

Other substances are occasionally employed, having in view the 
better preservation of wine, but many of these are unhealthful in 
their effects on the system. Such, for example, is the use of calcium 
sulphate, which is converted into potassium sulphate, or the use of 
alum, sulphuric or other acids, etc. Impure alcohol holding fusel 



STIMULANTS AND BEVERAGES 245 

oil is sometimes added. The object of storing wine in enormous 
tuns is to diminish the surface exposed to the air in comparison with 
the bulk. 

THE VARIETIES OF WINES 

The following classification of wines, with the examples and 
comments, is largely derived from Chambers, and will be found 
convenient and practical from a purely dietetic standpoint. 

Wines may be classed as — 

I. Strong Dry Wines. II. Strong Sweet Wines. III. Aromatic 
Wines. IV. Acid Wines. V. Sparkling Wines. VI. Perfect W"ines. 
VII. Rough or Astringent Wines. 

I. Strong Dry Wines are those in which the sugar of the ex- 
pressed grape juice or " must " has fermented into alcohol, either 
by process of time or by artificial means. When left to itself, this 
alcoholic fermentation is extremely slow, occupying many years 
before its completion, but the natural process is better than any 
artificial one yet discovered. These wines also contain considerable 
alcohol, often 17 or 18 per cent, which makes them less available for 
general dietetic uses than weaker wines. Examples are strong, dry 
old sherry, port, Madeira, and Johannisberg. (The name " sherry " 
is often used as a generic term for white wines grown in Spain.) 

These wines, especially sherry, are sometimes used for stimula- 
tion in fevers or other diseases, in lieu of spirits, where the taste of 
the latter is strongly disliked. If drunk too freely they congest the 
stomach, and have the evil effects of strong spirits or of strong 
alcohol in general. (See Alcohol, Evil Effects.) They often con- 
tain some sugar, and taken with meals they may interfere with diges- 
tion, causing acetic fermentation, and especially disturbing the di- 
gestion of fats. 

Port is a wine in which the original fermentation has been ar- 
rested by the addition of alcohol, and it has a proverbially bad 
reputation for precipitating attacks of gout. In England, where 
much more is consumed than in the United States, it is even held 
responsible for causing the disease in some instances. 

It is well known that port improves more by long rest in the 
bottle than does any other wine. It is a useful temporary tonic, 
and, like claret, its astringency makes it serviceable in diarrhceal 
diseases, but many persons, especially in this country, find it alto- 
gether too heavy for daily use. This is not altogether due to its 
high percentage of alcohol, for a greater quantity of strong spirits 
will sometimes be found to do less damage. It is a poor wine for 
dyspeptics, and should be proscribed in all bilious states, lithiasis, 
cases with tendency to gallstone formation, gravel, gout, and rheu- 
matism. It has been largely replaced by claret of late years as a 
dinner wine. 



246 STIMULANTS, BEVERAGES, CONDIMENTS 

Port as well as Burgundy is sometimes spiced or " mulled," 
and prescribed diluted, as a tonic for elderly people. Taken before 
retiring, with a biscuit, or mixed with a light gruel, it may promote 
their sleep. 

II. Strong Sweet Wines are those which contain, either natural 
or artificially added, fruit sugar in sufficient quantity to exercise a 
preservative influence, and further fermentation is checked by boiled 
grape juice. Examples are Tokay, Malaga, sweet sherry, sweet 
champagne, Malmsey, Madeira, Lachrymse Christi, and other vins 
de luxe. They are much too sweet to be drunk in quantity, but this 
quality is sometimes made to disguise the bitterness of other sub- 
stances, as when Tokay is added to coca extract to make " wine 
of coca." If long kept, the sweetness is reduced but the peculiar 
agreeable flavour remains. Alcohol may be added to further insure 
preservation and increase the strength of the wine, and sweet port is 
sometimes made in this manner. 

The sweet heavy wines, such as sweet port, sherry, and Madeira, 
contain about 19 to 22.5 per cent of alcohol, 3.5 to 6 per cent of 
sugar, and about 0.50 per cent of acid. Malaga and Tokay contain 
more sugar and less alcohol. 

The chief use of these wines is not for tonic or dietetic purposes, 
but for their agreeable flavour. They are better taken between 
meals, if at all, both because the delicacy of their flavour is more 
appreciated when the mouth is free from other tastes and because 
their sweetness may interfere with digestion. Like all sweet wines, 
they must be forbidden to the gouty, rheumatic, bilious, lithsemic, 
and dyspeptic. 

III. Aromatic Wines have a peculiarly choice bouquet, and con- 
tain abundance of essential oils with considerable alcohol. They are 
best when drunk in their native countries — in Spain, France, Italy, 
etc. — for they bear transportation poorly unless re-enforced by ad- 
ditional alcohol, which detracts from their delicacy of flavour and 
aroma. Examples are the choicer Rhine wines, Moselle, Capri, Cha- 
teau-Yquem, and Orvieto. Some wines of this class are " more 
noted for their acid than aroma " (Chambers). Such are white 
Burgundy (Chablis) and white Bordeaux (Sauterne), which are 
often drunk with salads and rich foods. The Moselle and Rhine 
districts produce acid grapes with abundant aroma, and the 
wines which bear these names are many of them almost free from 
sugar. 

IV. Acid Wines owe their distinguishing property to tartaric acid 
chiefly, but wines which have turned sour on keeping or by exposure 
to the air contain acetic acid and resemble vinegar. 

V. Sparkling Wines are those in which carbon-dioxide gas, 
formed by fermentation after the wine is bottled, is set free upon 
uncorking, and continues to be liberated for some time thereafter. 



STIMULANTS AND BEVERAGES 247 

The gas gives additional flavour to the wine and increases its ex- 
hilarating effect. Such wines are champagnes, sparkling Moselle, 
and vino d'Asti. The better the wine, the longer it continues to 
give off gas and aroma after uncorking. Good champagne is bottled 
under a pressure of about five atmospheres. 

These wines, especially good champagne, are very serviceable 
for invalids, and some persons with delicate stomachs can digest no 
other form of alcohol ; but poor champagne causes gastric derange- 
ment sooner than any other wine. 

When nausea and vomiting exist they have special power for 
allaying the gastric irritation. ■ They are absorbed with great rapid- 
ity, and act promptly by invigorating the nervous system and cir- 
culation. They may sometimes be substituted for spirits in fevers 
when there is need of alcoholic stimulation. Their cost, unfortu- 
nately, places them out of the reach of many, and it also affords much 
temptation for adulteration. 

Champagne. — The essential difference between champagne and 
other wines is that it contains carbon-dioxide gas in solution. 

Manufacture. — Champagne is made of different grades, repre- 
senting the first, second, and third expressing of the grape juice 
respectively. It contains approximately 12 per cent of alcohol, 
or less. 

Good champagne is made as follows: The juice is allowed to 
ferment for about two weeks, when it is poured into casks and kept 
for a period varying from two to six months, after which it is bottled 
and kept from two to nine years in racks arranged to hold the bottles 
with their mouths down, so that on opening them all sediment which 
has collected in their necks can be removed or " disgorged." The 
final process is the addition of sugar-candy sirup dissolved in old 
wine and white cognac brandy. For the " sec " brand 8 per cent of 
sirup is added ; for other brands varying quantities up to 16 per cent 
are poured in. A little alcohol, too, may be added, after which the 
wine is again corked, and left standing. 

French champagnes sometimes have liqueurs or cordials added 
for flavouring, but American champagnes depend solely upon the 
grape flavour. 

Dryness. — Much emphasis is placed on the value of " dry " cham- 
pagne for invalids, which means that the sugar which it originally 
contained has disappeared, and hence the wine is less apt to pro- 
duce flatulent dyspepsia or aggravate conditions in which saccha- 
rine food is harmful. True " dryness " is the result of age, and is 
due to a very slow conversion of sugar into alcohol, such as goes 
oil in port wine which has been kept for several decades, but, as 
pointed out by Chambers, this process of slow ripening does not 
remunerate the dealer, so he induces a quicker acetous fermentation 
by which all the sugar is transformed in a few months, instead of 
iS 



248 STIMULANTS, BEVERAGES, CONDIMENTS 

many years, or else he puts but half the quantity of sirup into the 
wine — 4 instead of 8 per cent. It is champagne manufactured in this 
manner which is usually shipped out of France for foreign consump- 
tion, and hence this wine often has a " dry " taste because it is sour, 
and not because it is wholly free from sugar. When this is the case, 
it imparts a bright-red colour to blue litmus, even after the free car- 
bonic acid which it contains has been allowed to escape. The various 
brands called " dry," " extra dry," or " sec" " tres sec," usually rep- 
resent only varying degrees of acidity. " Brut " refers to wines left 
to undergo natural fermentation. 

Undoubtedly one of the reasons why champagne is so exhilarat- 
ing to many persons is the fact that it is promptly and completely 
absorbed, even when taken with food. Its effects are therefore 
suddenly felt by the nervous system. 

VI. " Perfect " Wines are those which are classified by Cham- 
bers as having their several ingredients — " alcohol, water, sugar, 
ethereal flavours, fruity extractives, and acids " — commingled with- 
out giving characteristic prominence to either one. Such are many 
of the best clarets, but the red wines usually, from one cause or 
another, fall under some other class. 

Bordeaux, Burgundy. — The best Bordeaux is fully fermented, 
but the commoner Burgundies and red Rhones contain " too much 
fruity extractive, which decomposes unless re-enforced by alcohol, 
and are unwholesome unless ripe when drunk " (Chambers). When 
a red wine is so decomposed it is unfit for consumption. Re-fer- 
mentation in it may be discovered by lightly corking a half-filled 
bottle, letting it stand for some hours in a warm place, and then 
shaking it. If carbonic acid is present, it will rise in bubbles and 
expel the cork. Wine of this sort deranges digestion, causing acid 
eructations and gastric discomfort. 

Prime Burgundies, on the contrary, like Chambertin, have more 
" body," and, because they contain a larger percentage of alcohol, 
do not ferment. Moleschott gives the average volumetric percent- 
age of alcohol in red wines as follows : Clarets or red Bordeaux, 
10.61 ; red Rhone, 10.39; rc( ^ Burgundy, 11. 19. 

Therapeutic Uses. — Prime clarets, Bordeaux, and Burgundies are 
useful tonics for invalids, to be given in moderation with meals, or 
in some cases with a biscuit or light sandwich as a luncheon between 
meals. They contain little or no sugar, and are of excellent service 
in convalescence from protracted fevers, such as typhoid, or from the 
grippe, etc. The lighter forms, if of good quality, are the best form 
of wine for daily consumption by brain workers or those whose 
sedentary habits or whose advanced age make desirable a slight 
stimulus to appetite and digestion. Claret is almost the only wine 
which it is at all safe to allow gouty or diabetic patients. Of red 
Bordeaux or clarets, Pavy says : 



STIMULANTS AND BEVERAGES 



249 



" There is scarcely any condition in which they are calculated to 
disagree. They form a most suitable beverage for persons of a gouty 
or rheumatic disposition, and also for the dyspeptic. It may be said 
that they are not prone to turn sour upon the stomach themselves, 
nor to cause other articles to become sour ; neither do they provoke 
headache or derangement in those who are subject to bilious dis- 
orders." 

Burgundy, being a much fuller wine than claret, is more service- 
able where anaemia and malnutrition exist if it can be borne without 
giving rise to headache. 

Beaujolais is intermediate in its effects between claret and Bur- 
gundy. 

Some years ago, when scurvy was common in the English navy, 
it was found that the substitution of red wines for spirits in the 
ration had a decided prophylactic influence. 

In diarrhoea, the red wines, according to Lichtenstern, have a 
twofold beneficial action : first, by depressing exalted reflex excita- 
bility in visceral nerves, and, secondly, by controlling intestinal 
putrefaction. Those which contain considerable tannin are also 
mildly astringent. 

VII. Rough Wines are those in which an excess of tannin causes 
decided astringency. They usually contain pigment, but not much 
alcohol. Some clarets belong with this group. 

As a rule, these wines are not available for general dietetic or 
invalid use, and are mainly employed to add to other wines to 
aid in their preservation and otherwise alter them, although they 
are drunk by the peasants in the countries where they are pro- 
duced. 

Raisin Wine. — An inferior quality of wine is made by restoring 
the water of the grapes which has been lost by drying them into 
raisins. Wine is now sometimes made in France from raisins dried 
in California. 

Influence of Wines upon Digestion. — Roberts has thus determined 
the effect of several wines upon peptic digestion by adding together 
two grammes of dried beef-fibre, 0.15 per cent of hydrochloric acid, 
1 c. c. of glycerin extract of pepsin, varying proportions of hock, 
claret, or champagne, and water to 100 c. c. 



Proportion of Hock, Claret, or 
Champagne in the Digesting 
Mixture. 


TIME IN WHICH DIGESTION WAS COMPLETED. 
(NORMAL, IOO MINUTES.) 


Hock. 


Claret. 


Champagne. 


10 per cent 


100 minutes. 

115 
150 
Embarrassed. 


100 minutes. 
140 " 
180 " 


90 minutes. 
IOO " 


20 " " 


40 " " 


no " 


60 " •• 


Embarrassed. 180 









STIMULANTS, BEVERAGES, CONDIMENTS 



Liquors 

Strong spirits, such as rum, whisky, brandy, and gin, are the 
worst forms of alcohol for daily drinking, and liquors of this class 
are responsible for nine tenths of the evils of inebriety. In locali- 
ties where their consumption has been brought into competition 
with or has been superseded by that of beer, drunkenness has often 
diminished. As the system acquires toleration for the stronger 
forms of liquor, it is found that its desired effects can only be 
obtained by constantly increasing the strength or the frequency of 
the drinks, and meanwhile the alcohol absorbed is gradually con- 
verting the different tissues of the body into pathological specimens. 

The drinking of new and raw liquors is particularly injurious, 
for time mellows them somewhat and reduces the quantity of their 
most hurtful ingredient — fusel oil — while their flavour improves. 
The difference in taste of liquors depends upon the substances from 
which they are made much more than upon any 'skill in their manu- 
facture or modifications in their fermentation, circumstances which 
so materially affect wines. The taste varies with the relative quan- 
tity present of aldehyde, compound ether, higher alcohol (fusel oil), 
and volatile bases. 

Brandy and other strong spirits are distilled from a variety of 
carbohydrate foods : such are potatoes, corn, rye (whisky), beets, 
rice (arrack and sake), molasses (rum), crushed grapes, apples 
(applejack), peaches, plums, cherries (Kirsch), and other fruits. 
These spirits contain from 45 to 60 per cent of alcohol, besides cane 
sugar and extractives. 

French Cognac is a strong, pure brandy, distilled either from 
wine, or directly from crushed grapes. It may be coloured by cara- 
mel. Common brandy is distilled from wine. 

Whisky. — American whiskies are classed as (1) rye and (2) Bour- 
bon, from the county of that name in Kentucky. 

Manufacture. — The proportion of materials used in making the 
" mash " for distillation is, on the average, cornmeal 0.8, rye 0.1, and 
malt 0.1 (Leoser). This mixture is placed in tubs, and scalded with 
" slop," the refuse from former distillation. After cooling, it is 
raked, or mixed by a stick called a " masher." Water is added, and 
the mass ferments for two or three days. 

Sweet mash is scalded with water instead of slops, and yeast is 
added to induce fermentation. 

Sour-mash whisky is made without yeast but with slop. The 
wort is then heated by steam, and the low wines, called " singlings," 
are run off from the residue or slop and redistilled, and the whisky 
is ready for barrelling (Leoser). It should then be kept from three 
to five years to ripen, according to the details of its manufacture. 



STIMULANTS AND BEVERAGES 2$I 

Pure rye whisky is distilled by an identical process, but the corn 
is wholly replaced by rye. 

Scotch and Irish whiskies are distilled from a barley mash. 

American whiskies are kept in charred barrels, and grow darker 
from colour derived from the wood (Witthaus). Scotch whisky de- 
rives its colour from lying in old sherry casks. 

Proof whisky contains equal parts of absolute alcohol and water. 

Leoser says : " The difference ill quality in different kinds of 
whisky is infinitesimal, and for therapeutic processes may be neg- 
lected, provided the taste of the patient is consulted." 

The evil effects of poor whisky are largely due to the presence 
in excess of a regular constituent, an aldehyde called furfural. 

Gin is distilled from rye mash, and flavoured by immersing a bag 
of juniper berries in the vat towards the completion of distillation. 

It is variously known under the names Geneva, Hollands, and 
Schiedam, the two latter referring to its Dutch source, the former 
being derived from the French word for juniper, genievre, of which 
gin is a corruption (Pavy). Gin may contain 17 per cent of alcohol, 
but it is often diluted, and when sweetened besides, it is known as 
" Old Tom." 

Rum is distilled from a mash of molasses. The wort contains 
about 15 per cent of sugar, and the fermentation process requires 
from nine to fifteen days. Rum was formerly made in New England, 
but it now comes chiefly from the West Indies, and that made in 
Jamaica is considered the best. Other rum is made from rectified 
proof spirit. It is a liquor which improves very much on keeping 
for several years. The flavour of rum, which is principally due to 
butyric ether, is produced by adding molasses, caramel, and some- 
times fruits, such as pineapple or guava. Acetic and other ethers 
are also present. 

Therapeutic Uses of Liquors Compared. — The spirits in common 
use have different physiological action. As their alcoholic basis is 
substantially the same in quality, the effects are varied mainly by 
aromatics. Gin is the most distinctly diuretic of the liquors. Given 
with a little lemon juice and diluted with some effervescing water, 
it promptly increases the urinary secretion. Brandy is somewhat 
more astringent than whisky, which is sometimes laxative. Brandy 
is therefore to be preferred in cases of diarrhoea, but in this country 
at least it is very apt to be impure. The role of liquors as tonics 
and stimulants will be referred to under the heading of the different 
diseases in which they may be required, and their influence in pro- 
ducing alcoholism is discussed under that heading. 

Adulteration of Liquors and Wines. — Liquors are flavoured and 
also adulterated by a variety of substances. Among those men- 
tioned by Chambers as oftenest found are cocculus indicus, ginger, 
quassia, wormwood, caraway and coriander seeds, hartshorn shav- 



252 



STIMULANTS, BEVERAGES, CONDIMENTS 



nigs, nux vomica, gentian, alum, cream of tartar, chamomile, juniper 
berries, bitter almonds, orange peel, licorice, honey, rhatany, and 
catechu. 

Much of the cheapest claret sold in this country is little more 
than a decoction of logwood, and the flavour of some of the better 
grades is cleverly imitated. For example, Chateau-Latour is sophis- 
ticated with almonds or other nuts, Chateau-Lafitte with violets and 
nuts, and to other grades cherry juice is added. Wines are often 
adulterated with artificial pigments, alum, tannin, fusel oils, cider, 
perry, and lime salts. 

The cheaper grades of strong liquors contain an excess of fusel 
oil or amylic ether, which is not an adulterant in the sense that it 
has been added for sophistication, but because it is a poisonous 
natural product which is difficult to eliminate. It is responsible 
for much of the headache, foul tongue, nausea, dyspepsia, and even 
cirrhotic changes in the viscera which are incident to dram drinking. 

Liqueurs play no part in invalid diet. With the exception of 
absinthe and Angostura, they contain a very high percentage of 
sugar with essence, and they all have a large proportion of alcohol. 
They are used as luxuries, and are seductive beverages, for their 
agreeable flavour sometimes begets the habit of alcoholism. This 
is especially the case with absinthe. 

Analysts of Liqueurs (Rupp) 



[OO C. C. LIQUEUR. 



Absinthe. . . . 

Anise 

Kummel. . . . 
Peppermint. 

Angostura . . 
Curacoa 
Benedictine. 
Chartreuse. . 



ALCOHOL. 










Extracts. 


Sugar. 


Volume. 


Weight. 






Per cent. 


Per cent. 


Grammes. 


Gram.7nes. 


55-o 


44.O 


I.80 


1. 10 


40.0 


32.0 


33- 20 


30.9O 


32.5 


26.O 


29.80 


28.20 


35-o 


28.0 


44. CO 


43.20 


48.0 


38-4 


12. CO 


7-50 


52.5 


42.O 


27.90 


26.50 


53-0 


42.4 


35-°o 


33-40 


44.0 


35-2 


35-40 


34.OO 



Salts. 



Grammes. 
0.220 
O.3IO 
O.IOO 

0.090 
0.140 

0.075 

O.IIO 

0.091 



The essences are distilled or expressed from aromatic plants, and 
such colouring agents are used as saffron, cochineal, indigo, etc. 
Vermuth contains only 17 per cent of alcohol. 

The following table by Duckworth is a convenient summary of 
the average percentages of alcohol in round numbers in the different 
beverages above described : 



Spirits 35 to 44 per cent. 

Port wine 19 " 

Madeira 18 " 

Sherry 17 " 

Champagne n " 

Burgundy.. 10 " 



Bordeaux 8 per cent. 

Rhine wines 8 " " 

Porter 6 per cent or more. 

Ale 3 to 6 per cent. 

Cider 4 per cent. 



CONDIMENTS AND SPICES 253 

Fig Wine is made in countries bordering upon the Mediterranean, 
and has an alcoholic strength of between 7 and 8 per cent. It also 
contains considerable mannite. It is often used for the sophistication 
of grape wines. 

Cider. — Cider made from ripe apples usually contains from 4 to 
8 volumes per cent of alcohol besides malic acid, extractives, sugar, 
and salts. 

It is slightly laxative. The excess of carbonic acid generated by 
cider protects it from the atmospheric air, but when the gas dis- 
appears acetic fermentation converts the cider into vinegar. 

Cider is sometimes made from condensed apple juice, which is 
added in the proportion of one part to twenty of water when ready 
for use. 

CONDIMENTS AND SPICES 

Properties. — Condiments and spices are substances which are 
used as adjuncts to food, and which in themselves supply but little 
nourishment, their effect being mainly of a stimulating character 
either to the nerves of taste or secretion. They add flavour to 
otherwise insipid food, and relieve monotony in diet. Some condi- 
ments, such as mustard, contain a slight amount of nutritious mate- 
rial, but the total quantity of any of them which can be taken is so 
small in comparison with the bulk of the food that they may hardly 
be said to subserve nutrition. 

Curry powders of various sorts are prepared by mixing strong 
condiments, such as Cayenne pepper and ginger, with starchy food 
and turmeric. 

Some foods are themselves so stimulating to the mucous mem- 
brane that they answer the double purpose of food and condiment 
combined ; such, for example, are onions and garlic. 

In the mouth condiments produce an agreeable taste, with an 
increased flow of saliva, and the desire for food in the stomach is 
stimulated. They also increase the secretion of gastric juice. 

Uses. — In some dyspeptic conditions of the stomach accom- 
panied by local sensation of weight or oppression, or even of pain, 
the use with the food of strong condiments — such as mustard, Cay- 
enne pepper, or Tabasco — affords relief by exciting the functional 
activity of the stomach. Cayenne, in fact, is a favourite ingredient 
of various dinner pills. 

With the exception of salt, the use of which has been elsewhere 
fully described (p. 45), none of the condiments are absolutely in- 
dispensable in the sense of being essential for prolonging health, 
but so accustomed are all classes of men to their use from heredity 
or personal experience that, despite the aphorism of Plutarch that 
" hunger and salt should be man's only sauce," without other rel- 



254 STIMULANTS, BEVERAGES, CONDIMENTS 

ishes the appetite soon fails. There are many cases of feeble diges- 
tion and diminished activity of the gastric juice which are decidedly 
benefited by their use in moderation. 

Harmful Effects. — The use of some condiments is like!y to be 
abused, and this is particularly true of peppers, curry, pickles, and 
vinegar. If consumed habitually in excess, these substances excite 
gastric hyperemia and catarrh by overstimulation, and may disorder 
intestinal digestion as well. They at first cause more food to be 
eaten than necessary, and eventually destroy the appetite, develop- 
ing chronic dyspepsia of an aggravated type. Persons living in 
tropical climates where food and service are cheap are apt to lead 
indolent lives and indulge too liberally in the pleasures of the table, 
and the overloading of the stomach tempts them to add quantities 
of condiments to their food for the purpose of stimulating an already 
overworked digestive system to the performance of further duty. 
The heat of the climate prevents active exercise, which in turn re- 
duces the oxidation processes of the assimilated food. The rational 
diet for those not acclimated to the tropics should consist largely 
of vegetables and fruits, while nitrogenous food, strong condiments, 
spirits, bitter beer, etc., should be carefully shunned. I have seen 
one case of the ginger habit, in Bellevue Hospital, in a woman thirty 
years of age. It was first acquired by chewing the roots of Jamaica 
ginger, and subsequently the patient drank large quantities of the 
beverage sold under that name, and ate powdered ginger of every 
variety. The patient became maniacal and greatly emaciated. The 
symptoms in general resembled those of the cocaine habit. 

Varieties of Flavouring. — Next to salt (see p. 45), the most 
useful condiments are pepper, mustard, ginger, and vinegar, but 
much difference in taste exists in the use of condiments, and their 
selection is to some extent a race characteristic. Thus the Persian 
prefers his asafcetida, which no one else can tolerate ; the Spaniard 
and Mexican his garlic ; the East Indian his curry ; and the French- 
man his salad with vinegar. 

From long-continued association certain condiments appear to 
serve best with definite foods, and so accustomed are most persons 
to their combination that we cannot easily recall the one flavour with- 
out the other; thus mustard is associated with ham, black pepper 
with eggs, red pepper with raw oysters, vinegar with spinach and 
raw tomatoes, etc., and when deprived of the usual relish the food 
tastes insipid. Such details, insignificant as they may ordinarily 
appear, become very important for certain classes of invalids in whom 
it is necessary to preserve the appetite by pleasing the palate in order 
that they may take food enough to sustain them. Such are cases of 
phthisis, empyema, and other forms of chronic wasting diseases. 

Often by varying the flavouring slightly from day to day two or 
three times as much of the same food will be taken by the invalid. 



CONDIMENTS AND SPICES 255 

A skilful use of condiments may do away with the necessity for alco- 
holic stimulation and serve a better purpose. 

Beef tea and meat broths, which become wearisome to many in- 
valids, will be often relished if a taste of some savoury aromatic herb 
be added, such as parsley, thyme, sage, marjoram, or mint. 

Mustard does not greatly stimulate the gastric secretion, but many 
persons find that it increases the appetite somewhat, and it often pro- 
duces a sensation of warmth or mild burning in the stomach or a feel- 
ing akin to hunger. It is used to advantage in moderation in salad 
dressings or with cold meat, and is sometimes serviceable in those 
cases in which the main difficulty is a lack of appetite without special 
enfeeblement of the digestive organs, but it has very little positive 
value, and while its use in health may be left as a question of indi- 
vidual taste, it is scarcely ever to be specifically recommended, and 
its abuse, like that of all condiments, may give rise to gastric irrita- 
tion. The general irritating effect of mustard in large quantities 
applied to the skin or gastric mucous membrane is well known, and 
diluted with lukewarm water (a teaspoonful of mustard to a pint of 
water) it constitutes a very prompt and valuable emetic. Mustard is 
said to make the evacuations of the bowels somewhat more moist 
(Ringer). The seeds are sometimes eaten for their laxative action. 
The diuretic effect which has been attributed to mustard is not 
established. 

Black pepper is the berry of a plant, the Piper nigrum, which grows 
in the West Indies, Sumatra, and other Eastern countries. The 
whole berry is dried and ground for use. 

While pepper is made from the same berry by previously soaking 
off the outer husk in water. About thirteen million pounds of black 
pepper are annually consumed in the United States. It is often 
adulterated, and to avoid deception it may be purchased in corns 
and freshly ground at the table. 

Cayenne pepper is not a true pepper, but is made from the crushed 
pod of various species of Capsicum. It grows in the tropics, espe- 
cially along the eastern coast of Africa and in Zanzibar. 

The Capsicum annnum is cultivated in this country for the making 
of pickles from the large unripe green fruit. 

The Capsicum fastigiatum is a variety employed medicinally, and 
recognised by the Pharmacopoeia. 

Chilies is a common name given to this pepper in England, and 
chili sauce is an essence prepared from it. It is the strongest variety 
of capsicum. 

Capsicum, called also Cayenne or red pepper, like mustard, is a 
strong irritant to both the skin and the mucous membranes. Over- 
doses of it excite violent local inflammation and gastro-enteritis. 
Like mustard, it is doubtful whether capsicum in any degree pro- 
motes the secretion of the gastric juice, but it sometimes stimulates 



256 STIMULANTS, BEVERAGES, CONDIMENTS 

a flagging appetite and produces a feeling of warmth in the stomach ; 
the latter readily becomes tolerant to increasing doses of capsicum, 
and it is found that more and more is required by those who have to 
use it habitually to excite the accustomed stimulation. Its chief use 
is as a substitute for alcohol for dipsomaniacs, especially where the 
effort is being made to stop drinking abruptly. Its fiery nature tem- 
porarily satisfies the craving of the stomach. When chronic alco- 
holic gastritis exists, the stomach digestion is often improved and 
the craving to satisfy it by strong liquor may be relieved by the 
tincture of capsicum given in doses of ten or fifteen minims diluted. 

The use of capsicum in health is far from necessary, but it forms 
an agreeable condiment for many persons. It forms an ingredient 
of many dinner pills which are taken by elderly people with inactive 
digestion for the purpose of promoting the appetite. 

Red pepper, like black, is often adulterated. When pure it may 
be entirely suspended in water. If any precipitate falls it is probably 
red lead. 

Capers are the flower buds of a bush, the Capparis spinosce, which 
grows in Eastern countries bordering on the Mediterranean. They 
are preserved in salt and vinegar, and are used for flavouring sauces 
for mutton and other foods. They contain tannin, volatile oil, yel- 
low pigment, and a bitter principle. 

Spices are solely of value in giving variety of taste to the food, 
and hence tempting invalids or convalescents with lagging appe- 
tites to eat more. Comparatively tasteless food, such as rice, may 
be made very attractive by spicing. 

For children the most useful flavouring substances are cinnamon 
and ginger, and, although not a spice, vanilla extract. For invalids 
there may be added nutmeg and cloves, although any agreeable spice 
may be used in moderation, such as mace or allspice. Patients who 
will not drink hot water when it is ordered will often do so if they 
can steep a few cloves or a small piece of cinnamon in it, and this 
can rarely do harm. Those who object to the taste of milk punches, 
custards, and simple farinaceous foods will often take these sub- 
stances when slightly flavoured with a trace of some agreeable spice. 
The latter as ordinarily used for flavouring is never injurious. Only 
in large doses are such spices as those above mentioned capable 
of such irritant action in the stomach as may be produced by curry 
or mustard. Several cases of nutmeg poisoning are recorded. The 
symptoms are excessive thirst, vertigo, and muscular prostration. 
Such effects are produced by taking a whole nutmeg, ground and 
mixed with hot water. 

Ginger is useful both as a condiment and as a food. It is the 
dried root of the Zinziber officinale, which grows in Jamaica, China, 
and elsewhere. The rhizome is scraped and either dried and pow- 
dered, or, if it is to be preserved, it is washed and boiled for twenty- 



CONDIMENTS AND SPICES 257 

four hours, and then soaked for another day in salt water. It is 
then washed, sun-dried, and boiled for half a day with an equal 
weight of sugar (Clark). It is placed in jars for several days, and 
then once more boiled, when it is finally sealed in jars. It is excel- 
lent for flavouring rice and other insipid farinaceous foods for con- 
valescents and children. 

Vanilla is derived from vanilla beans, grown in Mexico,- Java, 
and other tropical regions. It makes an agreeable flavouring ex- 
tract for foods for invalids and children, such as farinaceous 
gruels, custards, blancmange, or ice cream, for, unlike the spices, 
it is very bland. Its chief use is in the manufacture of chocolate 
(p. 223). 

Vinegars are made from wine, beer, cider, various fruits, and even 
from the dry distillation of wood. They contain, besides acetic 
acid, traces of dextrin, sugar, organic acids, pigment, extractives, 
and acetic ether. White vinegar is the best in taste and odour. 

The acetic acid in good French vinegar exists in the proportion 
of 5 per cent. Ordinary table vinegar contains between 2 and 7 
per cent. 

The acidity enables this condiment to soften muscle fibre so 
that the digestion is facilitated of tough meat, such as corned beef, 
boiled beef, and other foods with hard fibre, like salmon, lobsters, 
or hard-boiled eggs. 

The action of mild acids, such as vinegar, favours the digestion 
of tough cellulose, and aids the formation of sugar. For this reason 
vinegar is a wholesome addition to coarse, fibrous, or stringy vege- 
tables, such as beets, cabbage, spinach, lettuce, celery, etc., and to 
raw vegetables, such as cucumbers, cole, lettuce, and like ma- 
terials used in salads. Vinegar is often eaten with baked beans, but 
it is said to make their legumin less soluble (Chambers). If vine- 
gar taken in a salad dressing disagrees, white wine may be substi- 
tuted with pepper or mustard and oil. 

Vinegar has a well-known antiseptic and preservative action, and 
hence its use for pickling fish, oysters, fruits, and vegetables. 

Pickles are indigestible, and should take no part in an invalid 
dietary. 

An excess of vinegar habitually consumed with pickles, or other- 
wise, causes anaemia and emaciation by lessening the number of red 
corpuscles and reducing the alkalinity of the blood. 

Vinegar is often adulterated, or spurious articles are substituted 
for it. This is especially true of that used for the cheaper varieties 
of pickles, and weak sulphuric acid is quite commonly employed for 
this purpose. 

Sauces, such as Worcestershire, Tabasco, tomato catsup, etc., 
are used to stimulate a flagging appetite, and add flavour to soups, 
broths, etc. Taken in great moderation, they are not injurious, and 



258 STIMULANTS, BEVERAGES, CONDIMENTS 

in cases of alcoholism they are sometimes useful by inducing the 
patient to take more food and less liquor. 

For invalids, for whom strong sauces of this kind should always 
be forbidden, a very good substitute may be made for use with 
broiled fish, etc., as suggested by Chambers, by boiling a few plain 
aromatic herbs, like parsley or mint, in a little water, and adding 
pepper and salt. 

Horseradish is a condiment which excites the flow of saliva and 
gastric juice when eaten early in the course of a meal with meat 
or raw oysters, or otherwise. 



PART III 

COOKING 

FOOD PREPARATION AND PRESERVATION 

THE QUANTITY OF FOOD REQUIRED 



COOKING 



The Object of cooking Food. — While man is so constituted that 
it is possible for him to live upon raw food for a considerable length 
of time, it is apparently designed by Nature that a large portion of 
his food should be cooked, for there are no savage races known 
who do not practise the art of cooking, in however elementary a 
fashion, and progress in the scale of development and civilisation is 
uniformly accompanied by advance in the art of cooking. Pre- 
historic man may have lived wholly on raw food, berries, fruits, 
shellfish, etc., but this diet is not suited for most tribes of man 
to-day, although the northern Eskimo still prefers to eat his meat 
raw and frozen. 

It is owing to the practice of cookery that the dietary of civil- 
ised man has been so much enlarged, and that it covers a wider 
range of materials than that which serves for the nourishment of the 
lower animals. There are many articles of diet in common use, and 
many others which may be employed as food in an emergency, 
which are not only unpalatable but are wholly indigestible in the 
raw state, but which are rendered nutritious by cooking, and it is 
far less difficult to modify the mechanical preparation of foods than 
the secretions which digest them. 

Generally speaking, foods, excepting fruits, having organised 
structure require cooking. 

Of the different varieties of food, that which is derived from 
animals as a rule requires cooking more than vegetable food. It is 
well known that some vegetables and most fruits are eaten raw by 
preference without palling upon the appetite, but raw meat of almost 
any kind soon becomes wearisome, and if consumed exclusively may 
even excite disgust. Raw milk, eggs, and bivalves are an exception 

259 



260 FOOD PREPARATION AND PRESERVATION • 

to this statement. The process of cooking food accomplishes in 
general the following purposes : 

I. Cooking develops certain flavours in the food, in meat par- 
ticularly, which are agreeable to the palate, and thereby enables man 
to secure variety in taste, which is so important a stimulus to the 
appetite. 

II. Most food is altered in consistence and made softer by cook- 
ing, although this is not always the case (eggs, for example, become 
harder when boiled). The food is therefore easier masticated and 
mixed with the various digestive fluids. It may be observed that 
the mere question of solidity of food does not necessarily imply 
greater toughness — in fact, the albuminous ingredients of meat are 
coagulated and made actually more solid by cooking, but at the 
same time they become much less tough or are more friable, in 
which condition they are more easily ground, torn, and separated 
by the teeth. 

III. The chemical changes produced in food by cooking seem in 
some instances to favour the action of the digestive juices upon the 
food. This is particularly true of some of the forms of starch and 
of many meats. 

Comparatively little attention has been paid to the chemical alter- 
ations produced in food by the various processes of cooking. Analy- 
ses of food are usually conducted upon the raw materials, and the 
important alterations which are occasioned by heat in various de- 
grees are still imperfectly understood by most persons. 

IV. By cooking, many varieties of parasites and germs which 
may be contained in the food are destroyed, and bad food which 
might otherwise be highly poisonous or injurious is made perfectly 
harmless. 

V. The temperature of food which is sometimes eaten hot may 
in some cases favour the digestive processes, although the frnpor- 
tance of this consideration may be exaggerated. 

VI. The appearance of the food may be improved, and it becomes 
more appetising on this account. 

Varieties of Cooking. — The several processes of cooking which 
are in common use are as follows : i. Boiling. 2. Stewing. 3. Roast- 
ing. 4. Grilling, or broiling. 5. Frying. 6. Braising. 7. Baking. 
8. Steaming. 

There is undoubted advantage in varying the different methods 
of cooking as well as of flavouring the food from time to time. Mo- 
notony of diet and of flavours lessens the appetite and fails to stimu- 
late the digestive organs into activity. When a reasonable variety 
of food cannot be obtained, variety in cookery may be made to re- 
place its advantages to a great extent. Every one is familiar with 
the effect on the appetite of an occasional change of cooks or of a 
meal served in unwonted surroundings. 



COOKING . 26l 

It is not within the scope of this work to discuss the details of 
cooking for the sick. Miss Nightingale wrote that " a good sick- 
cook will save the digestion half its work," and invalid cookery 
should form the basis of every trained nurse's education. It is 
impossible here to do more than explain the theory of the chief 
methods of cooking and suggest occasionally their influence upon 
digestion. As a rule, twice-cooked meats are undesirable for in- 
valids. They are apt to be drier and less nutritious and digestible 
than when fresh. In meat " hash," for example, the meat fibre is too 
much hardened. Such preparations are often made too greasy by 
recooking for delicate stomachs. The same statement applies to 
canned meats when warmed over, for they have been already cooked 
once in the tin. 

It is undesirable to combine foods which require different periods 
for their thorough cooking. For example, soup needs less boiling 
than the vegetables added to it, and they should be partially cooked 
alone beforehand, or they will be underdone. 

The necessary heat for cooking is obtainable in many ways — 
from coal, wood, gas, oil, steam, and even electricity — and these 
different methods each possess advantages for particular foods. 

Cooking, as a rule, at a prolonged low temperature is more eco- 
nomical in its results upon food than a much shorter application of 
high heat, and this is the theory of the famous " Count Rumford 
kitchen." 

1. Boiling. — The primitive method of boiling water consisted in 
heating the water in a hollow dug in the ground by plunging in hot 
stones taken out of the fire. Later, as the arts of pottery making 
and metal working became known, utensils were employed. 

In some excellent remarks by Williams on the subject of so- 
called boiled food, he points out that the expression " boiled " beef, 
or eggs, or potatoes, implying that the food has been boiled in the 
same manner in which the water is boiled, is an absurdity. The food 
is merely heated by immersion in boiling water, and even such 
water as is contained in the meat or potato is not itself boiled in the 
process, for, he says, " its boiling point is higher than that of the 
surrounding water, owing to the salts it holds in solution. Thus, as 
a matter of chemical form the boiled leg of mutton is one that has 
been cooked but not boiled, while the roasted leg of mutton is one 
that has been partially boiled. Much of the constituent water of flesh 
is boiled out and fairly driven away as vapour during roasting or 
baking, and the fat on its surface is also more or less dissociated 
into its chemical elements, carbon and water, as shown by the brown- 
ing due to the separated carbon." 

It is a scientific fact which is not appreciated by many persons 
that when water has once reached the boiling point, its temperature 
cannot be further elevated until it is all converted into steam, for all 



262 FOOD PREPARATION AND PRESERVATION 

the additional heat which is required above that needed to warm the 
water and drive off the air-bubbles in the process of ebullition is 
expended in vapourising the water into steam. Consequently, how- 
ever hot the fire, or however prolonged the cooking, the tempera-' 
ture of the food suspended in boiling water cannot be increased 
above that of the water itself; and, in fact, the temperature of the 
interior of large masses of food, like potatoes or meat, is by no 
means as great as that of the surrounding water. For this reason, 
piling fuel upon the fire when water has once reached the boiling 
point will have no further effect than that of accelerating the rate 
of ebullition, without actually raising the temperature of the water 
or any food immersed in it. 

Five and a half times as much heat is required to convert water 
at the boiling point into steam as that which is needed to raise water 
from the freezing to the boiling point. Count Rumford over a cen- 
tury ago remarked that, while the boiling temperature of water varies 
considerably at different levels, meat or eggs are just as thoroughly 
cooked at an elevation in which the water boils at 209.5 as they 
are at the sea level, where the boiling temperature is 212 F. 

There is practically no distinction to be made between " simmer- 
ing " and boiling as a process of cooking. The violent boiling of 
some foods tends to soften them somewhat on account of the effect 
of the commotion produced in the water by the rising bubbles which 
cause currents to form that carry particles of suspended food with 
them and triturate them. 

The operation of boiling if continued for an hour or more gradu- 
ally converts the connective tissue of meat fibre into gelatin, which 
is partially dissolved .in water, and the heat of the boiling water 
usually melts a little of the fat, which, being unable to mix with the 
water, forms a scum upon the surface. A small proportion of the 
juices of meat usually osmoses or soaks out into the surrounding 
water, and the aqueous solution thus formed is called broth or bou- 
illon. The richness of the broth will depend principally upon the 
method of conducting the boiling process. When it is desired to 
have the broth as nutritious as possible the meat must be finely 
minced and put into cold water, which is gradually warmed but not 
actually brought to the boiling point. By this process the juices of 
the meat are slightly dissolved out into the warm water, and there- 
after, if the temperature is not carried above 160 F., coagulation 
of the albumin in the muscle fibres does not occur, and more and 
more of their constituents are dissolved out into the surrounding 
water — but this is not true boiling. In this manner the natural 
flavour is very much better preserved ; in fact, the common extracts 
of meat are made by soaking finely chopped meat in cold water and 
subsequently evaporating the water from the ingredients which are 
found in it. 



COOKING 263 

On the other hand, when broth is not wanted for nutriment it is 
desirable to prevent the solution of the juices in the water as much 
as possible, and this is accomplished by immersing the meat suddenly 
into water actually boiling, where it should be left for five minutes, 
by which time the outer layer of the mass will be hardened by coag- 
ulation and will have a firm coating which is not permeated by the 
juices within. When meat is cooked in this manner the broth is 
scarcely of any food value, but the meat is much more palatable. 
After the boiling temperature of the water has been maintained for 
five minutes the further cooking should be continued at a lower 
temperature of, say, 165 to 170 F. If the heat is less than this, the 
interior of the joint or other piece of meat is imperfectly cooked 
and its albumin is insufficiently coagulated, so that it has a raw 
appearance. If the actual boiling point is long maintained, the 
albumin is too firmly coagulated, and the meat becomes tough and 
stringy. The latter error in boiling is very commonly perpetrated 
by cooks, and it must be observed that the coagulation point of 
different forms of albumin varies considerably, ranging from below 
90 to above 165 F., and since many varieties of albumin occur in 
the different kinds of animal food which are in common use, it will 
be found that they are not all equally well cooked by exactly the 
same temperature. It is important that the coagulation temperature 
of a given albumin should not be greatly exceeded or long main- 
tained if the food is to remain tender and digestible. Parkes says 
that ammonium sulphite is liberated by continued boiling, and also 
an acid resembling acetic acid. 

When meat is plunged into boiling water so that the external 
layers are solidified some of the water which they contain is squeezed 
out into the surrounding fluid, and an actual loss of weight in the 
meat occurs which may reach as high as 30 per cent. 

The addition of salt to water in boiling fish or meat is described 
by Williams as having a threefold action : (1) It directly acts on 
superficial albumin with coagulating effect ; (2) it slightly raises the 
boiling point of the water ; (3) by increasing the density of the water, 
the exosmosis or oozing out of the juices is less active, and hence 
the flavour is better retained. 

When very salt meat is to be cooked, if steeped too long in boil- 
ing water its nutritive properties are impaired, the muscle sarcolem- 
ma becomes too hard, and the meat tasteless and tough. In such 
cases it may be well to boil meat less completely, and finish the 
cooking by some other method, such as frying. 

2. Stewing 1 . — Stewing differs from boiling in the fact that the 
juices of the meat or vegetables are dissolved in the heated water, 
whereas in boiling, the juices are kept from passing out into the 
water by the coagulation of the external surface of the food mass 
produced by immersing it suddenly into boiling water. The proper 
x 9 



264 FOOD PREPARATION AND PRESERVATION 

temperature for stewing is between 135 and 160 F. In thick stews 
the juices dissolved in the water are eaten together with the cooked 
food, but in some instances, as in the making of beef tea and some 
kinds of soups, the aqueous solution only is used. Obviously, the 
more the food is subdivided the greater the surface exposed to the 
solvent action of the water, and hence the object of mincing meat 
thoroughly which is to be used in the preparation of beef tea. If 
such minced meat has been soaked for a long time in cold water, a 
part of the albumin and the extractive materials are obtained in 
solution, but the meat which is left is colourless, tasteless, and un- 
palatable ; in fact, animals fed upon it soon deteriorate in strength. 

The manner in which stewing differs from other processes of 
cooking is well described by Williams, who says : " Instead of the 
meat itself surrounding and enveloping the juices, as it should when 
boiled, roasted, grilled, or fried, we demand in a stew that the juices 
shall surround or envelop the meat." And more or less water enters 
the substance of the meat to replace the juices which have passed 
out by osmosis and diffusion into the surrounding fluid. After meat 
has been stewed for some time a scum containing a little coagulated 
albumin and more or less fat is usually seen floating upon the sur- 
face. This is usually removed in the preparation of beef tea for 
invalids in order to make it more palatable and more agreeable to 
the eye, but its removal is at the expense of considerable nutritious 
material. In the preparation of extracts of meat, such as Liebig's 
Extractum Carnis, the scum is removed before the solution is con- 
centrated by evaporation. 

Stews which are simply made in the manner described above, and 
which consist largely of meat and plain sliced vegetables, are fairly 
digestible ; but if other materials or rich sauces are added to them, 
this is not the case, and if saturated with fat, they are quite unfit 
for invalids. As both the solid substance of the meat and vegetables 
and the fluid materials which have been extracted from them are 
eaten together in the stew, this is an economical form of preparing 
food. Nothing is lost by evaporation, and nothing is thrown 
away. 

3. Roasting. 4. Grilling. — The processes of roasting and grill- 
ing or broiling, when performed over a very hot fire, result in cook- 
ing the meat in a manner which is in some respects analogous to 
stewing ; in fact, the interior portions of the meat are stewed in their 
own juices instead of in water (Williams). A coating of coagulated 
albumin forms upon the outer surface of the meat, while the albu- 
minous material or myosin of the interior is gradually warmed and 
more slowly coagulated. The outer coating prevents the evapora- 
tion of the juices of the meat which, together with the extractive 
materials, are retained, and add flavour to it. Roasted and broiled 
meats therefore have a decided advantage in flavour as well as in 



COOKING 265 

nutritive value over meat which has been boiled for a long time, 
although the latter may be tender and easily digested. 

Roasting and broiling are the most universal methods of cook- 
ing. For them the savage or the hunter requires no utensils, but 
boiling implies the aid of the potter or worker in metals. The 
Polynesian cooks his meat by roasting it on a hot stone, and 
sprinkles it with sea water to obtain the salt. The primitive hunter 
incases his meat or fowl, skin and all, in damp clay and roasts it in 
hot coals. The Australian savage, the lowest type of man, does all 
his cooking by roasting. 

In roasting, the high temperature which is applied suddenly to 
the meat produces a firmer coagulation of its outer layers than 
occurs with boiling. Owing to this fact, the natural juices of the 
meat are almost completely retained, and, as in boiling, the heat 
should be strong when first applied, but it may subsequently be 
reduced to prevent charring of the surface. This may be accom- 
plished by removing the meat farther away from the fire. 

The process of roasting and grilling is conducted mainly by 
radiant heat, although there is slight convection through the air. 
The main object of an oven is to prevent burning by uneven 
cooking. 

The principle of a proper roasting oven is formulated by Wil- 
liams, who says " the meat should be cooked by the action of radiant 
heat projected towards it from all sides while it is immersed in an 
atmosphere nearly saturated with its own vapour," and the heat 
applied after reaching a maximum is kept uniform throughout the 
process. 

In boiling or stewing, the heat is applied to the meat by convec- 
tion through water, and this is an important discrimination because 
the air which surrounds the roasting meat is constantly removing 
the water which tends to evaporate upon its surface, and therefore 
to dry the external surface of the meat. From 20 to 24 per cent of 
water is lost in this manner, and the meat therefore weighs less. 
The evaporation of this water, which continually passes from the 
interior of the meat towards the outer surface, produces a loss of 
heat in the meat itself which keeps the interior from becoming over- 
heated. If the roasting or broiling is long continued, the water 
gradually passes out more and more from the interior of the mass, 
which finally becomes dry and hardened or burned. If too much air 
surrounds the meat, it is poorly roasted, dry, and leathery, whereas 
if the heat is applied more directly by radiation from glowing embers, 
the sudden hardening of the outer coating of the meat, even though 
it be slightly burned, forms a barrier against the evaporation of 
water from the interior. 

Broiling or grilling is a means of quick cooking which requires 
very much less time than roasting or boiling, because intense heat is 



266 FOOD PREPARATION AND PRESERVATION 

applied to comparatively small pieces of meat or fish. It is really 
roasting on a smaller scale. 

The object of broiling as well as of quick roasting should be to 
raise the interior of the mass promptly to the point of coagulation, 
or about 180 F., so that the water formed shall not have time to 
wholly evaporate. It is consequently advisable for the meat to be 
cooked as near the glowing surface as possible to increase the radia- 
tion and diminish the convection of air currents (Williams). It is 
for this reason that steaks and chops are often better cooked in 
restaurants, where specially adapted grills are used which bring the 
meat in closer relation to a radiant surface of glowing coals than it 
is usually possible in domestic cookery. A properly cooked steak 
or chop is thickened in the centre, but if badly grilled it is thin and 
dry. It should be remembered that the evaporation depends upon 
the extent of the surface of the meat, and for this reason thinly cut 
steaks or chops become comparatively dry and shrivelled in the 
centre. This principle is well described by Williams, who says that 
" the smaller the joint to be roasted, the higher the temperature to 
which its surface should be exposed," and when very large masses 
of meat are being cooked, it becomes necessary to secure time for 
the heat to penetrate into the interior without drying up the outside. 
This object is accomplished by constantly basting the surface in 
order to keep it wet and prevent evaporation, for while the surface 
is moistened, its temperature will not rise above the boiling point 
of the liquid which is used to moisten it. Pouring melted fat or 
melted butter over the meat checks evaporation almost completely, 
and in the case of large joints it prevents the external portion from 
becoming too dry and indigestible before the albumin of the interior 
has been coagulated. Small lean joints of meat require more fre- 
quent basting with fat. 

The roasting of any meat, however, cannot be accomplished 
without the effusion of some of the meat juice and the melting of a 
portion of the more superficial fat and of gelatin. These substances 
together constitute the meat gravy, which is itself quite nutritious 
and which is advantageously used for basting the meat to prevent 
drying, as well as to distribute the heat more uniformly over the 
surface. In overroasted or " burned " meat the external layers be- 
come scorched or charred, and this is due chiefly to the carbonising 
of the fat. Before the fat has become fully burned, certain volatile 
fatty acids are liberated which have a very disagreeable odour, and 
various products are developed which are not only of no value for 
nutrition, but which may be positively irritating to the alimentary 
canal. According to Yeo, for beef, mutton, and game, a tempera- 
ture of 130 F. is sufficient for proper cooking, and the meat is 
" rare " or " underdone," retaining a good deal of its reddish colour ; 
but veal and poultry should be cooked at a higher temperature — at 



COOKING 267 

from 158 to 160° F. These temperatures are lower than those 
often used, and apply rather to the degree of heat which is to be 
maintained after the meat is first placed in position for roasting, 
when, as previously stated, the temperature may be much higher. 

Game or meat which is " high " or somewhat tainted is extremely 
repulsive if cooked by boiling or stewing, when it disintegrates more 
or less and the elements of decomposition pass into and flavour the 
whole mass. Such meat, however, is sometimes palatable, and is 
not necessarily unwholesome if cooked by roasting, when the ex- 
ternal layers which have first commenced to decompose are thor- 
oughly browned and thereby disinfected. Some persons prefer that 
a leg of mutton should be hung until it becomes slightly odorous 
before it is roasted, but it must be fresh tor boiling. 

5. Frying. — Frying is a process of cooking by which the heat is 
transmitted by the contact of the food with melted fat, butter, or oil, 
and not by radiation, as in the case of broiling or roasting. As ex- 
plained by Williams, the fat does not necessarily boil, for the food, 
as well as the fatty material itself, may contain a considerable pro- 
portion of water which, by being suddenly vaporised, produces the 
familiar spluttering which accompanies the process of frying. 

The boiling point of fats is very much above that of water, and 
the vaporisation of the latter is complete at 212 F. Between 300 
and 500 F. may be required to vaporise the so-called volatile oils, 
but fats and oils used in cooking do not apply to this class, and 
when heated above 400 F. they turn dark brown or black and emit a 
disagreeable odour and smoke, leaving a non-volatile carbon residue. 

The process of frying bears somewhat the same relation to boil- 
ing that the broiling of meat does, in that the heat employed is 
considerably greater. It is suddenly applied, and as a result the 
external surface of the food mass is coagulated and hardened before 
the juices in the interior have time to escape. For this reason, deli- 
cate fish, like the trout, is much more highly flavoured and palatable 
when fried than boiled. More or less butyric acid is developed from 
fat in frying. 

The popular idea in regard to frying is that the fat used, whether 
butter, lard, or drippings, is simply for the purpose of preventing 
food from adhering to the frying pan, but, from the explanation of 
the process quoted above, it is seen that this is not the case, and the 
best frying is done by immersing the food completely in a bath of 
fat or oil. Even olive or sperm oil may be used for this purpose, 
and the fish or other food is lowered in an open wire basket or net- 
ting into a deep pan which contains the fat, in which it is completely 
submerged. There is no danger of the fat soaking into the food if 
it is sufficiently hot and if the process is not too long continued, for, 
as stated by Williams, " the water amid the fibres of the fish is boil- 
ing and driving out steam so rapidly that no fat can enter if the 



268 FOOD PREPARATION AND PRESERVATION 

heat is well maintained to the last moment." Fritters cooked in 
this way are light and puffy from the sudden expansion of the water 
which they contain into large bubbles of steam, and are consequently 
decidedly more digestible. Bacon fries in its own fat. 

Frying is less perfectly understood by cooks than almost any 
other method of preparing meat, and the process as usually carried 
out results in very unwholesome products. The pans used are too 
shallow, and the food and fat are apt to become scorched. 

When the meat or other material is dipped into hot melted oil or 
fat, more or less of it clings to the surface of the food, and for this 
reason may render it unfit for persons with feeble digestive powers. 
In the case of fish cooked in this manner with their scales, the fat 
which adheres to them may be easily removed when eaten, and the 
meat within will be found to be quite digestible ; but meat, such as 
steak, cooked by frying is notoriously indigestible. Salt meat may 
be cooked first by boiling before frying, as in the case of hams, 
although the latter may be subsequently roasted instead of fried. 
Such meats always require prolonged cooking. According to Yeo, 
the addition of a little vinegar tends to make them more tender. 

6. Braising. — Braising is a method of cooking meat by which it 
is immersed in a solution of vegetable and animal juices called 
" braise," contained in a covered vessel, in which it is exposed to a 
strong but not boiling temperature. It is of value especially for 
cooking tough meat of any sort or meat which is too fresh or young. 
The cover of the kettle is so arranged as to prevent evaporation 
from occurring to any extent ; the meat becomes permeated in the 
long cooking with the juices of fresh vegetables and herbs, and is 
kept from drying. 

Towards the end of the process cooking-sherry or spices may be 
added, such as cloves or mace, or thin slices of bacon. The amount 
of fluid used should be but barely sufficient to cover the meat, and 
in this way the surrounding broth is kept very concentrated. Some- 
times the meat which is braised is partially roasted. 

7. Baking. — Baked meat is prepared by cooking in a confined 
space, which prevents the volatile products which are driven off in 
roasting from escaping, and consequently the meat has a somewhat 
stronger and less delicate flavour than when roasted ; it is also richer, 
and disagrees with dyspeptics. It becomes saturated with empyreu- 
matic oils unless its surface is protected by a pie crust, but even that 
does not add to its digestibility. 

The baking of bread is described on page 137. 

8. Steaming. — Cooking by steaming is a method but little used, 
and is mainly applied to cereals, puddings, etc. 

Soups. — Meat soups are made by continued boiling, which con- 
verts the connective tissue of meat fibres into gelatin, which is grad- 
ually dissolved into the water. The soup thus becomes an aqueous 



COOKING 269 

solution of gelatin, with some of the extracts of the meat for flavour- 
ing. Whatever albumin is dissolved and what little fat may be 
melted forms a scum on the surface. The insoluble albumin be- 
comes coagulated and floats about in small particles, which are 
strained away if the soup is to be clear, but this process makes it 
less nutritious for invalids. If a really rich soup or nutritious broth 
is to be made from any piece of meat, so much of the latter is dis- 
solved into the water that the residue is tasteless, tough, and so 
indigestible that it is practically useless. On the other hand, there 
are many scraps of meat or parts which are unsightly or less useful 
for food from which very nutritious broth may be made, and the 
inedible bones are utilised in the same manner. 

The extent to which soups and broths may be made nutritious 
depends largely upon the character of the meat used, and Parkes 
placed meats in the following order in regard to the nutritive value 
of their broths, commencing with the strongest : Chicken, mutton, 
and beef. He said that the best broth made from beef contains 150 
grains of nitrogenous nutriment to the pint and 90 grains of salts, 
for nearly all of the salts of the beef, chiefly chlorides and phos- 
phates, dissolve out into the surrounding water. 

When a few drops of dilute hydrochloric acid are added to minced 
meat immersed in water, the acid converts the muscle albumin into 
syntonin, which is soluble in cold water, and after soaking in it for 
several hours a moderately nutritious broth can be obtained. Such 
broth may be heated to 130 F. without coagulation, when it will be 
found to contain nearly 50 per cent of the meat albumin (Parkes). 
(See Receipts for Beef Tea.) 

Cooking of Fish. — Fish may be cooked by boiling, grilling, 
baking, frying, or stewing. Of these several methods, boiling is 
decidedly the most advantageous for persons with feeble digestions, 
and next in order is broiling. When fish is boiled without the 
addition of salt to the water it becomes soft and disintegrated, but if 
boiled in sea water or artificially salted water it maintains its shape 
and flavour. The quantity of salt present regulates the osmosis of 
the juices of the fish into the water. As a rule, fish requires much 
less time than meat for cooking. 

If fried fish is to be eaten by dyspeptics, it should be cooked 
whole, and the skin must be carefully removed subsequently. It is 
never as digestible as boiled fish. 

Cooking of Vegetables. — The object of cooking vegetables, as in 
the case of cooking meat, is to render them more digestible, to give 
variety, to modify their flavour, and in some cases to preserve them. 

Some coarse vegetables, such as turnips, carrots, beats, and pota- 
toes, while they make good raw food for animals, are unpalatable 
and indigestible for man, and require softening and alteration by 
prolonged boiling in soft water or by some other form of cooking. 



2/0 FOOD PREPARATION AND PRESERVATION 

The cooking of vegetables macerates the cellular fibres or walls of 
the cells and softens their contents, rendering the vegetable much 
more easy of mastication, while the effect of the heat and moisture 
is to cause swelling and rupture of the starch granules, in which con- 
dition they are more easily and promptly acted upon by the starch- 
digesting ferments contained in the saliva and pancreatic juice. 

Many vegetables contain albuminous substances, besides sugars, 
gums, and starches. The albuminous material is coagulated by ap- 
propriate temperature and the other matters are more or less soluble 
in water. 

Most vegetables contain a very large percentage of water in their 
natural state, but in many of the cooking processes to which they 
are subjected, excepting perhaps in baking potatoes and the like, 
water is always added in considerable quantity, either hot or cold. 

FOOD CONCENTRATION-CONDENSED FOOD 

The concentration of food is based upon the fact that many foods 
contain a large percentage of free water, which can be driven off by 
evaporation, thereby reducing the weight, and usually the bulk of 
the food as well. Slight further condensation may be accomplished 
by pressure through machinery which is capable of applying a force 
of several tons to the square inch. 

Drying. Desiccation. Extracts. — If the process of drying is not 
carried beyond a partial evaporation, the food is called " condensed." 
It may, however, be continued until the food is wholly dry, in which 
case the substance may be either " desiccated " — i. e., torn into 
shreds — or pulverised. Condensed and powdered foods may be 
added to other foods in order to thicken them or add to their 
nutritive power. 

The nutritive principles of foods may be extracted by glycerin 
or acid solutions and other materials, and the resulting extract is con- 
densed by evaporation to the consistence of a paste or powder. Be- 
yond this it is not possible to concentrate foods by chemical process, 
for a definite bulk of food must be daily consumed from which to 
derive the energy for the body and the substance needed for repair. 

Drying is conducted either in the heat of the sun or by artificial 
means. The class of dried foods embraces the various forms of 
dried and desiccated meat and fish, dried milk, dried vegetables and 
fruits, such as peas, beans, lentils, corn, okra, apples, peaches, cocoa- 
nuts, grapes (raisins), figs, etc. The addition of sugar, flour, or salt 
by abstracting moisture, aids the drying and helps to prevent decom- 
position. (See Food Preservation by Drying, p. 274.) 

Milk may be dried in vacuo and preserved by itself as a powder, 
or mingled with other materials, such as malt and various starchy 
foods. Condensed milk has been already described (p. 93). 



FOOD CONCENTRATION— CONDENSED FOOD 2J\ 

Eggs may also be successfully dried ; they keep well, especially 
when mixed with farinaceous materials (p. 106). 

Froissart relates how the King of France in the invasion of 
England in 1386 had the yolks of eggs packed and stored in bar- 
rels to furnish rations for the troops. Egg albumin dries in the form 
of thin scales which may be indefinitely preserved. 

Meat. — The preservation of meat and fish by drying is probably 
the oldest, as it is the most primitive, method in use. Meat drying 
is practised extensively among savage tribes in almost all parts of 
the worid, but especially where purity of the atmosphere combined 
with intense heat and dryness of climate will cause the water to 
evaporate from the meat so rapidly that germs do not have time to 
decompose it. For this purpose only lean meat can be used, as the 
fat does not part with its water with sufficient readiness. Dried 
meat loses much in weight, becomes hard and tough, and in many 
cases tasteless. It is therefore usually indigestible, and requires 
prolonged cooking and proper seasoning. When prepared in this 
way, the drying process may be applied very thoroughly, and the 
food is more easily cooked and seasoned. Dried meat may be pre- 
digested, evaporated, powdered, and made into a paste for broths, 
or used to re-enforce various food preparations for invalids. Pow- 
dered meat is sometimes mixed with sugar and salt, or pulverised 
dried cooked vegetables, bread, etc. Meat extracts have been de- 
scribed in detail on pp. in to 118. 

Pemmican is a preparation of dried powdered meat, which has 
been described on p. 197. 

Dried vegetables keep even better than dried meats. Tea and 
coffee are good examples of dried vegetable substances. They may 
be extracted and then concentrated by evaporation. Potatoes are 
concentrated by drying to less than one third of their original weight, 
and they may be thus preserved in slices or in granular form. Many 
other vegetables are prepared by drying, and, in addition, some are 
compressed, as, for example, cabbage, cauliflower, carrots, etc. The 
compression still further excludes air and moisture. As a rule, dried 
vegetables are only serviceable for relieving monotony of diet when 
fresh vegetables cannot be obtained. Desiccated vegetables have 
been used with some success in the United States navy, but they 
have less antiscorbutic property than fresh foods. 

Bread may be preserved for a long time by drying, but it usually 
becomes tasteless, and is useful in this condition only in emergencies, 
or to make variety in the rations of sea biscuits, hard-tack, etc., 
which are furnished to soldiers and sailors in active service. 

Major Woodruff, Assistant Surgeon, U. S. A., writes of this 
subject : " The Germans have been the first to take advantage of 
drying and compressing processes in the manufacture of a dried, 
compressed bread. The great difficulty in the use of bread for field 



272 FOOD PREPARATION AND PRESERVATION 

service consists in the inability to supply it so that it will keep a long 
time and be digestible. Hard-tack is ruinous to many soldiers, as 
already pointed out. If baker's bread is compressed, it sinks into 
a heavy dough. Only strong stomachs can digest it, and it is far 
worse than the wet, soggy, hot breakfast bread with which we culti- 
vate dyspepsia. If the bread is merely dried, it is too bulky for 
transportation. By a new process, which probably consists in dry- 
ing the bread and at the same time compressing it by improved 
machinery, the Germans have secured a variety of field bread which 
is spoken of in very high terms. Small bits of it thrown into soup 
swell up like a dried sponge when thrown into hot water. The 
soldiers are said to be very fond of it, and as far as known it is 
entirely successful. . . . 

" The French Department of Intendance has been experimenting 
with dried bread, which is said to be superior for campaigning pur- 
poses both to biscuit and ordinary bread. From the results of the 
experiment, which are given in the Revue du Service de lTntendance 
Militaire, it appears that this dried bread will absorb from five to six 
times its own weight of water, milk, tea, coffee, or bouillon. Biscuit 
absorbs hardly its own weight of liquid, although when thor- 
oughly dried it contains only about 10 per cent of water, whereas 
the bread contains from 12 to 14 per cent. It can be made in 
cubes of convenient form." 



Diet of Concentrated Foods 

There are many complex dried foods in market prepared espe- 
cially for invalid diet, and supposed to possess high nutritive value 
with small bulk. As compared with fresh food, their lighter weight 
and greater concentration make them valuable articles for temporary 
invalid diet, but they cannot be said to possess any special advan- 
tage over freshly made broths, scraped beef, etc., excepting in those 
cases in which it is important to lessen the bulk and increase the 
strength of the food. 

Attempts have from time to time been made in the German army 
and elsewhere to supply healthy men with a daily diet of concen- 
trated foods. If this could be done, it would be of great economic 
advantage for troops on the march, explorers in unknown countries, 
sailors on long voyages, and for use in many ways, but after a few 
days or a week of such treatment men lose in weight and deteriorate 
in strength. It is not found practical to give food for any length 
of time in which the total solid ingredients are concentrated to less 
than twenty-two or twenty-three ounces for the day's ration, al- 
though for a few days food may be used in which they have been 
reduced to ten or twelve ounces (Parkes). Pea meal (p. 164) and 
pemmican (p. 197) are the most noted rations of this class, to 



FOOD CONCENTRATION— CONDENSED FOOD 



273 



which bacon, hard-tack, concentrated meat extracts, coffee, and 
chocolate are often added. 

In a series of very instructive and important articles upon Mili- 
tary Food, published in the Journal of the American Cavalry Asso- 
ciation, Major Woodruff says : " Concentration only means the 
exclusion of the indigestible portions and part of the water. Thus 
the garrison ration gives to each man about five pounds of food, of 
which only four pounds are eaten, and it is impossible to condense 
this amount so that it will be much less than three pounds. All foods 
that are compressed and dried still contain from 5 to 12 per cent of 
water. The German soldier's war ration is equivalent to about two 
pounds of water-free food in the above sense. This is not enough 
for American soldiers during hard work, yet it is possible in an 
emergency to give the soldier fairly good nourishment with these 
improved foods, and not allow the weight to be over two pounds, 
as seen in the following table, in which the analyses are only ap- 
proximate : 





GRAMMES. 


Calories. 




Articles. 


Protein. 


Fats. 


Carbo- 
hydrates. 


Salts. 


Weights. 


3 cubes dried compressed 
bread, J pound each 

3 packages compressed soup, 
6 ounces each 


35 
100 


4 
I50 


250 
200 

450 


2 

28 


1,233 
2,625 


f pound. 

i " 


3 tablets compressed tea or 
coffee ready for use, possi- 
bly a tablet of dried fruit. . 


Total 


135 


154 


30 


3,858 


* 2 pounds. 





* Gross weight. 

" The composition of the bread is assumed to be the same as 
ordinary flour, and the tablets of soup can be manufactured of the 
given composition. As usually made, the tablets do not contain so 
much fat, which is here purposely increased in order to give the 
necessary energy. Even with this increase they would not contain 
as much as the first specimens of Erbswurst. 

" For purposes of detached service the United States soldier has 
been supplied, as seen in the following table : 



I pound hard-tack. . . . , 

-f pound bacon , 

Coffee, sugar, and salt. , 



Total 





GRAMMES. 




Calories. 


Protein. 


Fats. 


Carbo- 
hydrates. 


Salts. 


50 
27 


5 
236 


340 


2i 

J 9 


1,644 
2,310 


77 


241 


340 


30 


3,954 



Weights. 



I pound. 



2 pounds. 



274 FOOD PREPARATION AND PRESERVATION 



Food Preservation 

The different methods of food preservation have of late years 
received much attention, for it is owing to them very largely that 
it is possible to maintain large armies and navies in action and to 
permit of the aggregation of men in communities away from all 
immediate sources of food supply. 

It was originally believed that contact with air was per se the 
cause of the decomposition of food, but it is now known that the 
great number of germs contained in even comparatively " pure " 
atmospheric air are the agents of putrefaction rather than the air 
itself, but the exclusion of the latter implies the exclusion of the 
former. 

The different methods of preserving foods are therefore all de- 
pendent upon the principle of preventing fermentative changes which 
are liable to occur when germs, derived either from the atmospheric 
air or contamination with unclean substances, come in contact with 
foods under favourable conditions of warmth and moisture. The 
conditions which are inimical to the development of bacteria are 
those which may be successfully adopted for the preservation of 
food. 

Ferments and putrefactive germs require for their activity a fair 
degree of moisture, a moderately warm temperature, which for many 
putrefactive germs ranges between 6o° and ioo° F., while certain 
germs must, in addition, have free oxygen derived from the atmos- 
pheric air. 

The principal means employed for preserving food are included 
under the following headings : 

I. Drying. II. Smoking. III. Salting. IV. Freezing. V. Re- 
frigeration. VI. Sterilisation. VII. Exclusion of Air — Canning. 
VIII. Addition of Antiseptic and Preservative Substances. 

I. Drying. — Drying in the sun or before a fire is probably the 
oldest of methods of preserving food. At present it is used mainly 
for fruits and vegetables, although in some excessively dry and clear 
atmospheres, comparatively free from putrefactive bacteria, meat 
also may be preserved in this way. " Jerked " meat is kept by 
cutting it into thin slices and drying in the sun for several days. 
Familiar instances of preservation by drying are found in raisins, 
figs, dates, prunes, dried apples, peaches, desiccated cocoanut, etc. 
Some vegetables are also preserved in this manner, such as Lima 
beans, okra, corn, etc. Others are cut into slices and then dried, but 
the latter are apt to become tough and tasteless. Fish, such as the 
cod, is desiccated and preserved by drying, but with the addition of 
salt. The desiccated meats and vegetables which are used for 
making soups have the advantages of portability and permanency. 



FOOD CONCENTRATION— CONDENSED FOOD 275 

They are nutritious, and may be added to strong beef tea to increase 
its flavour and make it more palatable. 

This subject is further discussed under the heading Food Con- 
centration (p. 271). 

II. Smoking. — Smoking is the preservation of meat or fish by 
means of volatilised creosote and other substances developed from 
wood or peat smoke, which have an antiseptic action. It is chiefly 
applied to beef, tongue, ham, bacon, and fish. The meat or fish is 
hung in a confined chamber and saturated with wood smoke for a 
long time, so that it absorbs a small percentage of antiseptic mate- 
rials, the fat is prevented from becoming rancid and the albumin 
from putrefying. The smoking is commonly employed after salting 
and in connection with drying. Painting the surface of meat with a 
solution of wood creosote in vinegar has the same preservative 
action. 

The outer surface of meat, such as ham or bacon, preserved by 
smoking becomes considerably drier and tougher than the interior, 
but the latter is not made especially tough by the smoking if it was 
originally tender. Well-smoked bacon cut thin and thoroughly 
cooked is a digestible form of fatty food for tubercular patients, 
and smoked beef may sometimes be eaten for the sake of variety 
by patients who are placed upon a meat diet. The digestibility of 
hams is enhanced by the smoking process to which they are sub- 
jected. 

/The process of smoking is applied to fish upon a very large 
scale, and their digestibility and flavour cannot be said to be de- 
stroyed by it in many cases ; in fact, in some instances, as in those 
of smoked mackerel, herring, and salmon, while the flavour is 
very different from that of the fresh fish, it is agreeable to many per- 
sons, and these articles afford an important and appetising variety 
of food. 

III. Salting. — The process of salting is a primitive but still de- 
sirable method of preserving meat and fish. Salted meat usually 
becomes pale from the action of the salt upon the haemoglobin con- 
tained in the blood vessels of the muscle fibre. The addition of a 
little saltpetre helps to preserve the original reddish colour of salted 
meat. Salt also absorbs moisture from the food, and thus dries it 
while preserving it. 

Brine, a strong solution of common salt, may be used to tem- 
porarily preserve meat and other substances. The Chinese have 
long practised the art of preserving fruits, roots, and flowers in it. 
Corned beef is made by soaking the meat for some days in such a 
solution. The brine acts upon the muscular tissues and toughens 
it. Brine, concentrated by long-continued use, has been known to 
acquire poisonous properties from changes in the organic matter 
which has passed into it from the meat. The process of soak- 



276 FOOD PREPARATION AND PRESERVATION 

ing in brine causes much of the extractives and natural salts of 
the meat to osmose out from it, and the loss of organic mate- 
rial and salts occurring in this way has been estimated by Liebig 
and Parkes as equal to fully one third, for myosin itself is solu- 
ble in strong salt solution. For these reasons salted meats, such 
as corned beef, require prolonged cooking. Salt meat of all 
kinds is drier, less digestible, and slightly less nutritious than 
fresh meat. 

IV. Freezing. — Food may be kept in a frozen condition almost 
indefinitely. On being thawed, it must be cooked immediately, 
otherwise decomposition may set in at once, and, omitting milk 
and cream, food is not easily eaten in an actual frozen state, ex- 
cepting by the northern Eskimos, who take their meat in that form 
by preference. 

Meat and fish may be kept for many days frozen in blocks of ice 
without losing much in flavour, but vegetables are not as good when 
cooked after freezing. 

In 1867 Dr. Carl von Baer reported to the Royal Society of 
London the discovery in arctic Siberia of the body of a frozen 
mammoth, the meat of which was preserved. As this animal has 
been extinct since the days of prehistoric man, it afforded an illus- 
tration of the marvellous preservative power of intense cold. An- 
other such animal was found, in 1799, being eaten by wolves in 
Siberia. 

In 1861 the entire bodies of three Swiss guides, who forty-one 
years before had been buried by an avalanche over the Glacier de 
Boissons, were found in a state of excellent preservation. With 
these examples of the influence of cold, it is little wonder that meat 
may be preserved for a few months in ice and yet be quite fit to 
eat. In freezing meat for export it is subjected to a temperature 
of about 20 F. below zero. When quite hard the carcass is 
sewn in thin cotton cloth and placed in a refrigerating chamber on 
shipboard, where it keeps in good condition throughout long 
voyages. 

Meat actually frozen should be cooked as soon as it is thawed, 
and meat thus preserved is better cooked by roasting than boiling, 
unless it has been imperfectly thawed, in which case the central 
portion may remain frozen after the external layers have begun to 
cook, and when the latter are thoroughly roasted, the inside may 
still be found almost raw. Frozen meat loses 10 per cent of its 
nutritive value in cooking. Such meat has been transported in fresh 
condition as far as fifty miles inland in the Philippines. 

V. Refrigeration. — The process of refrigeration does not involve 
the actual freezing of meat or vegetables, but implies their preserva- 
tion in chambers at a temperature which is maintained but a few 
degrees above the freezing point. This causes less alteration in 



FOOD CONCENTRATION— CONDENSED FOOD 2JJ 

flavour than freezing. The cold is artificially generated, and beef, 
fish, fruits, and vegetables are now successfully transported for 
thousands of miles in refrigerator cars and rooms fitted for the 
purpose on steamships. 

The refrigerating processes applied to the preservation of meat, 
etc., are several. In most of them the actual reduction of tempera- 
ture of the meat is maintained by cold air and not by contact 
with ice. 

One method consists in the adaptation of the principle that com- 
pressed air on expanding derives the energy for its expansion from 
heat, which it abstracts from all surrounding bodies. The liberation 
of strongly compressed air, therefore, produces intense local cold in 
its immediate vicinity. The air is originally compressed by a force 
pump, and the heat which is developed by the compression is re- 
moved by a circulating stream of cold water. The cooled com- 
pressed air is then liberated with the effect described. Other 
apparatus is constructed on the principle of ice machines, which 
are operated by evaporating ammonia, which produces extreme 
cold. 

The keeping of meat by refrigeration is rapidly superseding the 
canning process for this kind of food, over which it has many decided 
advantages. Between 15 and 20 per cent of all the mutton eaten 
in Great Britain is brought from New Zealand and the River Plate 
in a refrigerated condition. 

Major Woodruff, U. S. A., writes : " The French Government 
is taking the initial step towards applying this new industry to the 
purposes of war. They have succeeded in keeping dressed beef in 
a perfect condition for three or four months with the present appli- 
ances. 

" A moment's thought will show what a revolution this matter 
of cold storage can make in military practices. It will obviate all 
necessity of keeping live cattle near the army, a system that so 
often results in diseased animals and fatal epidemics among the 
soldiers. It will help to wipe out of existence all the salt meats 
formerly supplied, and will thus avoid that large list of diseases of 
stomach, bowels, and nutrition that salt meats have been accused 
of causing." 

VI. Sterilisation. — By sterilisation of food is meant the process 
of rendering it germ-free by heat, and it includes the preservation 
of such food in sterilised vessels. Practically all thoroughly cooked 
food is for the time being " sterilised," and overdone meat keeps 
longer than underdone meat, for if the outer layers are firmly coag- 
ulated and dried by the heat of boiling or roasting, they form an 
envelope which is less pervious to the atmospheric air and germs. 
(See Cooking, pp. 260, 261.) 

Canned food (p. 278) is also sterilised, but the latter term is 



278 FOOD PREPARATION AND PRESERVATION 

applied chiefly to milk which has been treated by the method de- 
scribed on p. 84. 

VII. Exclusion of Air. — Exclusion of air from contact with food 
is accomplished not only in the process of canning, but by such 
means as varnishing or covering it with substances which are com- 
paratively impermeable, as in the case of varnishing eggs, covering 
fish with oil, or pate de foie gras with lard, etc. 

Eggs undergo decomposition from the entrance of the atmos- 
pheric air and germs through their shells, and this process may be 
prevented, sometimes for several years, by covering fresh eggs with 
almost any substance which is more impermeable than their shells, 
such as gum, fat, butter, oil, beeswax, or fresh milk of lime. The 
sawdust or salt in which eggs are commonly packed serves the 
double purpose of insuring safety in transportation and excluding 
to some degree the air. Similarly meat may be preserved by coating 
it with paraffin, gelatin, collodion, or layers of powdered charcoal 
or of lard after the manner of potted meats. Beef has been sent in 
good condition from Australia to England by merely dipping it into 
hogsheads of melted fat, in which it was allowed to remain after the 
fat cooled and solidified. The preservation of meats in air-tight 
skins, like sausages, has long been practised. 

When food is preserved by any of these methods care must be 
exercised to have it perfectly fresh at the start and to drive off by 
heat or otherwise any air which may be present in the food itself or 
in its containing vessel. 

Canning. — The original idea of the preservation of foods by can- 
ning was that the exclusion of air was the sole object necessary of 
accomplishment. It is now known, however, that many putrefactive 
bacteria are anaerobic, and that the food must be thoroughly steril- 
ised before the can is closed. This should be done by heat, but 
since it can also be accomplished by the addition of antiseptics, the 
introduction of the latter is practised by some unscrupulous manu- 
facturers to the detriment of the public health. 

The process of canning meat or vegetables is conducted as fol- 
lows : The food is placed in clean new tin cans, filling them as com- 
pletely as possible. Lids are then tightly soldered on the cans, 
leaving a minute pinhole opening only for the escape of air and 
steam. The cans are then immersed in a bath of boiling fluid, such 
as zinc-chloride solution, having a higher boiling point than the 
water within the cans. The latter boils, expels at first air, then 
steam, and thoroughly cooks the food, making it aseptic by killing 
all germs. Before the cans cool, their minute openings are soldered, 
and they are then ready for storage. 

The long boiling of meat in this manner toughens its fibres by 
hardening the syntonin. Such meat is apparently tender, but in 
reality it is not very digestible (Williams). 



FOOD CONCENTRATION— CONDENSED FOOD 279 

To avoid the necessity of cooking food at a high temperature 
in order to exclude the air, various modifications in the process of 
canning are employed. One of these — McCalFs — is based on the 
disinfection of the air by sodium sulphite. In another process sul- 
phurous acid and nitrogen are used to replace the air. 

H. W. Wiley, who has made an exhaustive study of canned 
foods, says, in an instructive report on Foods and Food Adulter- 
ants, made by him for the United States Department of Agriculture 
(Bull. No. 13, Part VIII): 

" All manner of food is canned, and that at prices which place it 
within the reach of the humblest pockets. Preserved food has been 
a great democratic factor, and has nearly obliterated one of the 
old lines of demarcation between the poor and the wealthy. Vege- 
tables out of season are no longer a luxury of the rich. ... In the 
American grocery pineapples from Singapore, salmon from British 
Columbia, fruit from California, peas from France, okra from Louisi- 
ana, sweet corn from New York, string beans from Scotland, mut- 
ton from Australia, sardines from Italy, stand side by side on the 
shelves."' 

Much light is thrown by Wiley upon the economic value of the 
substances under consideration in the following important state- 
ments from the report above quoted : 

" The quantity of dry food material in canned goods varies within 
wide limits. It is very low in such vegetables as string beans, aspara- 
gus, etc., and quite high in such materials as canned corn, succo- 
tash, and other bodies of that description. The lowest percentage 
of dry matter in string beans of American origin was 4.17. In other 
words, in buying one hundred pounds of such material the consumer 
purchases 95.83 pounds of water. 

" The price of the packages of string beans [bought in open 
market] varied within wide limits, depending both upon the size of 
the packages and the labels they bore. The highest price paid was 
thirty-five cents, and the weight of the contents of the package was 
a little over three pounds. The lowest price paid was ten cents, and 
this was paid in many instances. The highest price paid, according 
to the percentage of dry matter, was in sample 10,928, costing thirty 
cents and containing only two hundred and fifty-four grammes of 
string beans, 31. 1 grammes of dry matter, and 94.37 per cent of 
water. The price of the dry matter in this package was nearly 
one cent per gramme, which would be almost five dollars per 
pound. The enormous cost of food in canned goods is illus- 
trated to the fullest extent by this sample, showing in a striking 
way that such food materials must be regarded in the light of 
luxuries or condiments rather than as nutrients to support a 
healthy organism. An expenditure of ten or fifteen cents for a 
good article of flour or meal will procure as much nutriment for a 
20 



28o FOOD PREPARATION AND PRESERVATION 

family as the investment of three or four dollars in canned goods 
would. 

" A general view of the digestive experiments must lead to the 
conviction that the process of canning, especially when preservatives 
are employed, such as salicylic acid and sulphites, tends to diminish 
the digestibility of the albuminoid and other bodies. The low per- 
centage of digestible albuminoids will be remarked with some degree 
of astonishment in all the analytical tables." 

Of the dangers of poisoning from canned foods Wiley says : 
'• Vegetables are usually canned in the fresh state, and if they are in 
any degree spoiled at the time the fact is usually conspicuously evi- 
dent to the taste, so that the canner cannot afford to use them. 
Bacterial action seldom occurs in the can without bursting it or 
rendering it unsalable. Ptomaines may, however, develop where 
the canned food is allowed to stand for some time after open- 
ing, though even then this is unlikely in the case of preserved 
vegetables. 

" It may be said, therefore, that the principal risks to health which 
may arise from the use of canned foods are those due to the use of 
preservatives, or to the presence of the heavy metals — copper, tin, 
lead, and zinc. ... In this country there is no restriction whatever 
in regard to the character of the tin employed, and as a result of this 
the tin of some of the cans has been found to contain as high as 12 
per cent of lead. . . . The analyses of numerous samples of solder 
employed show that it contains fully 50 per cent of lead. In addi- 
tion to this there is no care taken to prevent the solder from coming 
in contact with the contents of the can. It is a rare thing to care- 
fully examine the contents of a can without finding pellets of solder 
somewhere therein. 

" Another great source of danger from lead has been disclosed by 
the analytical work, viz., in the use of glass vessels closed with lead 
tops or with rubber pads, in which sulphate of lead is found to exist." 

The frequency of poisoning by eating canned lobster, crabs, or 
shellfish is due mainly to the rapidity with which they decompose 
and develop ptomaines after the can has been opened. The contents 
of such a can partially used should not be kept until the next day. 

Canned beef is boiled and steamed under pressure at 250 F. 
It loses most of its extractives and has the tastelessness, therefore, 
of meat from which soup has been made. Vegetables may be added 
to improve the taste, either in the canning process or subsequently 
during cooking. 

Canned beef should be eaten promptly after opening, for it is 
liable to spoil within a few hours, especially in tropical climates. 
Severe gastro-enteric disorders may arise from eating such spoiled 
meat, and epidemics of such poisoning have been observed in a 
French garrison at Tours (1898), among the British troops in South 



FOOD CONCENTRATION— CONDENSED FOOD 28 1 

Africa (1900), and among our own troops in Cuba (1899). In the 
latter case much public scandal arose in connection with this subject, 
and from the further fact that manufacturers do not always resist 
the temptation to can meats of inferior quality, or which may be 
already partially decomposed, especially when hurried demands for 
canned goods are made to meet the exigencies of warfare. At the 
commencement of the Spanish-American War, in 1898, 7,000,000 
pounds of canned roast beef were purchased by the commissary de- 
partment for use by the United States soldiers. 

VIII. Antiseptic and Preservative Substances. — A long list of 
chemical substances have been used from time to time in the pres- 
ervation of food, but most of them have been supplanted by the 
safer process of canning, refrigeration, etc. 

The use of various antiseptic or preservative fluids is designed to 
prevent the activity of germs and fermentation. Sugar, like salt, in 
strong solution possesses decided antiseptic powers, and hence the 
employment of strong sirups for the preservation of fruits, and of 
sugar itself in making candied fruits. Other harmless preservative 
materials which are added are oils, chiefly serviceable for keeping 
fish, and vinegar and spirits of wine for pickling such products as 
chilies, tarragon, and shallot. 

Vinegar is used to preserve oysters, lobsters, and other sea 
food, as well as cucumbers, cauliflower, and other vegetables, as 
" pickles." Spices, mustard, and similar condiments are usually 
added. 

" Soused " fish, such as mackerel, are immersed in mixtures of 
cider vinegar flavoured with cloves, nutmeg, parsley, bay, onions, 
etc. After being " soused " once or twice the food is heated in the 
fluid to 140 F., flavouring substances are added, such as Worcester- 
shire sauce, extract of anchovy, and lemons, and the whole is put in 
air-tight jars (Clark). 

Among the materials sometimes employed for preserving foods 
may be mentioned the fumes of burning sulphur (sulphurous acid), 
acetic acid, weak carbolic acid, bisulphite of calcium, and the injec- 
tion into the blood vessels of meat of alum, chloride of aluminum, 
etc. Borax, boric and salicylic acids, formaldehyde, and other mate- 
rials have been extensively used in the preservation of milk, beer, 
meats, etc. Sodium sulphite is added to preserve chopped meat 
and Hamburger steak, and a mixture of borax, nitre, and salt is 
used in sausages. 

A new method of meat preservation has been introduced by 
a Mr. Jones in England. It consists of injecting the animal the 
moment after it is killed with a solution of borax, which is so 
uniformly distributed through the circulation to all the fibres of 
the meat that but a very small quantity of the antiseptic need be 
employed. 



282 FOOD PREPARATION AND PRESERVATION 

The use of borax and boric acid as food preservatives is so com- 
mon that it is a matter of great* importance to determine the influ- 
ence of these substances upon nutrition. This Prof. R. H. Chitten- 
den and William J. Gies have done. (American Journal of Physiol- 
ogy, No. I, 1898.) After elaborate experiments upon animals, these 
authors conclude as follows : Doses of borax up to 5 grammes per 
diem, continued for some time, do not disturb proteid metabolism or 
general nutrition. In larger doses borax retards proteid and fat as- 
similation and increases the weight of feces. Very large doses cause 
nausea, vomiting, mucous diarrhoea, and lessen the urine secre- 
tion (through which borax is eliminated). Boric acid in doses 
amounting to 10 or 15 grains per diem does not affect nutrition 
or proteid metabolism ; it does not affect the volume of urine or 
irritate the alimentary canal. Neither drug controls intestinal pu- 
trefaction. 

" Embalmed beef." This term is applied to meat which has been 
coated with a preservative antiseptic wash of some sort. A solution 
of boric acid is sometimes employed, but formalin is used more 
often. Flies avoid the coating and do not alight upon it. 

Formaldehyde, or formalin, is a strong antiseptic. It is not espe- 
cially harmful in moderate doses, but Halliburton, of London, has 
shown that it is especially active in inhibiting the action of the normal 
digestive ferments. It has proved highly injurious to infants when 
added to their milk. 

Glycerin has been used as a preservative, but it cannot be em- 
ployed in any quantity on account of its aperient action. Carbonate 
of sodium and sugar added to milk will preserve it for ten or twelve 
days (Yeo). 

It is true of practically all of these latter substances that food 
preserved by them if used in excess or for any length of time is apt 
to endanger the normal digestive functions, besides being somewhat 
less nutritious and more tasteless than other preparations. The use 
of many of them has been suppressed by law on account of their 
injurious properties, and the addition of salicylic acid to beer, milk, 
and other forms of animal food is everywhere condemned. 

Substitutes for Food 

Men are often placed under conditions in which, from poverty or 
exposure, sufficient quantities of food cannot be obtained. Under 
these circumstances, the craving of hunger may be diminished and 
the actual tissue waste may be retarded by the substitution of cer- 
tain mild stimulants and beverages. Tea, coffee, and tobacco all 
possess moderate action in this respect, and alcohol, under such 
conditions, is both a stimulant and a food. The natives of various 
barbarous or semicivilised countries, while performing long feats 



FOOD CONCENTRATION— CONDENSED FOOD 283 

of marching, being often unable to obtain sufficient food with regu- 
larity, make use of a variety of different substances for the purpose 
above indicated. Among these may be mentioned betel nut, kola 
nut, Siberian fungus, the cocoa leaf, and pepperwort, which are 
chewed from time to time ; hasheesh and opium, which are both 
eaten and smoked ; mate, and various forms of alcoholic fermented 
drinks. All these substances are used to enable men to prolong 
periods of fasting. 

Quantity of Food Required 

The quantity of food required to maintain the body in vigour 
depends upon the following conditions : 

1. External temperature. 2. Climate and season. 3. Clothing. 
4. Occupation, work, and exercise. 5. The state of individual health. 
6. Age. 7. Sex. 

In civilised communities, where cooking is a fine art, the num- 
ber and variety of food preparations is so great that the appetite is 
often stimulated beyond the requirements of the system, and conse- 
quently more food is eaten than is necessary or desirable to maintain 
the best standard of bodily health and vigour. 

Persons in this country who live in comfortable circumstances 
often eat a dozen or fifteen ounces of solid food at breakfast, and 
again at luncheon, and perhaps thirty ounces more at dinner, making 
a total of, say, fifty-five or sixty ounces, to which are added only 
fifty or fifty-five ounces of fluids. This is about a third more than 
the amount of solids actually needed, forty ounces of solid food 
(which equals twenty-three ounces of water-free food) being a fair 
average for the daily necessities of most persons, one fourth of which 
should be animal and three fourths vegetable food. They eat too 
much and drink too little fluid in proportion. (See Water, p. 19.) 

Gluttony results in overdevelopment and overwork of the digest- 
ive apparatus. The stomach and bowels become enlarged, the liver 
is engorged, and a predisposition is established to degenerative 
changes, fatty heart, etc. (See Overeating.) 

The most northern Eskimos, for example, who often eat but one 
meal a day and then gorge themselves with tough meat, develop big 
jaws and distended abdomens (Cooke). Hayes described Eskimos 
who ate daily from twelve to fifteen pounds of food, about one third 
of which was fat, and the rest mostly meat ; and Captain Hall, when 
on his arctic expedition, declares that he saw a native consume 
twenty pounds of raw meat and drink a quart of train oil within 
twenty-four hours. 

It is stated by competent students of dietetics that more disease 
arises from abuse of food in regard to both quantity and quality than 
from abuse of drink. 



284 FOOD PREPARATION AND PRESERVATION 

Sir Henry Thompson says (Diet in Relation to Age and Activ- 
ity) : " More mischief in the form of actual disease, of impaired 
vigour, and of shortened life accrues to civilised man, so far as I have 
observed in our own country and throughout western and cen- 
tral Europe, from erroneous habits in eating than from the habit- 
ual use of alcoholic drink, considerable as I know the evil of that 
to be." 

1. The external temperature increases the rate of oxidation pro- 
cesses in the body as it becomes colder by stimulating- the respira- 
tion and circulation, and there is a consequent increased demand 
for food. 

2. Climate and season influence the quantity of food eaten. Cold, 
bracing atmosphere stimulates the appetite, tempts one to exercise 
vigorously, and hence demands a larger consumption of fuel or food. 
A hot climate or season, with enervating, moist air, disposes man 
to languor and inactivity, and diminishes the appetite as well as the 
need for food. 

3. Abundant clothing in a cold climate conserves the body heat, 
and less food is therefore required to maintain life than if the body 
is but scantily clad. 

4. Exercise and muscular work also promote oxidation in the 
tissues and augment waste production from the muscles. This waste 
must be replaced, and energy must be supplied for work by addi- 
tional consumption of food. Outdoor work demands more food 
than indoor work, and mental labour less than physical. Where 
men are fed upon a carefully regulated diet — as in prisons — it is' 
found that those who are performing hard labour require about one 
fifth more solid food than the others. The hard-labour prison diet- 
ary in England comprises fifty ounces of solid food, chiefly bread 
and vegetables. (See Diet in Prisons.) 

5. The state of health of the individual greatly modifies the 
amount of food required both indirectly, through influencing exer- 
cise and work, and directly, by the local condition of the digestive 
system. 

Feeble and inactive persons may live on a third or less of the 
ordinary ration. Patients having chronic, purulent discharges, such 
as come from old sinuses, empyema, and tubercular abscesses, need 
large quantities of food — if they can digest it — to maintain their 
strength against the constant drain on their systems. 

The nursing mother should have abundant food, for she must 
eat for two. 

6. The age of the individual not only modifies the absolute 
amount of food required, but also the relative quantity in proportion 
to body weight. In the first year of life the infant grows six or 
eight inches, and at the end of a twelvemonth it should weigh two 
or three times as much again as at birth. This rapid growth necessi- 



FOOD CONCENTRATION— CONDENSED FOOD 285 

tates a relatively larger consumption of food than at any other period 
of life, and hence the child is fed at first once every two hours, and 
later every three hours. During the second year the proportionate 
growth is half that of the first year, and during the third year it is 
one third that of the first. After the third year the weight and growth 
increase more uniformly, but the child must still have a large relative 
quantity of food, a great proportion of which must be tissue-forming 
— i. e., nitrogenous. 

The following table is given by Prof. Arthur Goss (U. S. De- 
partment of Agriculture, Bulletin No. 54) : 

One meal of boy 14 to 16 years of age, inclusive, equivalent to 0.8 meal of man. 
One meal of girl 14 to 16 years of age, inclusive, equivalent to 0.7 meal of man. 
One meal of child 10 to 13 years of age, inclusive, equivalent to 0.6 meal of man. 
One meal of child 6 to 9 years of age, inclusive, equivalent to 0.5 meal of man. 
One meal of child 2 to 5 years of age, inclusive, equivalent to 0.4 meal of man. 
One meal of child under 2 years of age equivalent to 0.3 meal of man. 

The rapidly growing, active boy often eats more animal food than 
the adult, and the middle-aged man eats more than the aged. A 
man of seventy years may preserve good health on a quantity of 
food which would soon starve his grandson. 

7. Sex influences to a considerable extent the quantity of food 
consumed, but allowance must be made for totally different habits 
of life. There are many women w T ho eat as much as men, but the 
majority require less food, even when doing the same work. Under 
equal conditions in penal institutions men require about one fifth 
more solid food than women. Female factory operatives eat from 
•one tenth to one fifth less food than men. Prof. Arthur Goss gives 
the equivalent that one meal of woman averages 0.8 meal of man 
at moderate muscular labour. 

Mrs. E. H. Richards, as the result of observations (Food as a 
Factor in Student Life) upon 130 young women students at the 
University of Chicago, whose average weight was 120 pounds, gives 
the following table of food consumption in grammes per diem : 

Protein 120 

Fat 161 

Carbohydrates 4 02 

Total 659 

Potential energy in calories 3.3S3 

Women, on the average, weigh less than men, take less exercise, 
work less, and live less in the open air, and hence require less food. 
As a consequence of their habits of life they are more liable to dys- 
pepsia and constipation, which are also factors in reducing the quan- 
tity of their food below the standards for men. There are naturally 
many exceptions to all these general statements. 

It is ordinarily impossible or impracticable to definitely weigh the 



286 



FOOD PREPARATION AND PRESERVATION 



_ 



food for individual consumption, but where large numbers of men 
are being fed by contract in institutions, or as sailors or soldiers, or 
on exploring expeditions, it becomes necessary to estimate carefully 
the quantity of food required per diem to maintain normal health and 
vigour. To facilitate such estimates, tables have been carefully com- 
puted based upon the nutrient value of different foods. 

Quite exceptionally, persons are observed who subsist in good 
health upon an abnormally small quantity of food. They usually do 
but little work, and they are often, but not always, advanced in 
years. (See Food in Old Age, p. 308.) 

Fothergill referred to the case of one Wood, a miller of Billericay, 
who for eighteen years subsisted solely upon a daily allowance of 
sixteen ounces of flour, which he ate as sea biscuit made into a pud- 
ding. By this diet he reduced his figure from extreme corpulency 
to normal size, and maintained good bodily vigour. 

In the preparation of food to be eaten it is customary to allow 
10 per cent of waste in calculating the gross quantity for dietaries 
of institutions, army rations, etc. Mrs. E. H. Richards found that 
this percentage is somewhat too low. 

In computing the quantity of food needed for daily consumption 
its composition must be taken into account. The estimates of differ- 
ent authors vary somewhat in regard to the necessary quantity of 
different kinds of food in a mixed diet, but notwithstanding this 
there is a general correspondence between them. The chief dis- 
crepancy concerns the amount of fat to be eaten, and it will be 
noticed in the following tables that, as a rule, when the fat is cut 
down the carbohydrate estimate is correspondingly increased. 



Standard Daily Diet for an Adult Male at Ordinary Work 
Computed in grammes. 



Albuminates 

Fats 

Carbohydrates 

Salts 

Total water-free food.. . 



Mole- 


Pettenkofer 


schott. 


and Voit. 


130 


137 


84 


117 


404 


352 


30 


30 


648 


636 



Ranke. 



465 



Play- 
fair. 



IOO Ilg 

IOO 51 

24O ; 530 

25 



700 



Foster. 


Lan- 
dois. 


133 

95 
422 


I20 

90 

330 


650 


540 



Dujardin- 
Beaumetz. 



124 

55 
430 



609 



Healthy Adult Man, Abundant Diet and Rest (Bauer) 





Taken in. 


Consumed. 


Stored up. 


Albumin 


137 
117 

352 


137 

52 
352 




Fat 


65 


Carbohydrates 







FOOD CONCENTRATION— CONDENSED FOOD 



287 



An Ideal Ration of Solid Food (Mrs. E. H. Richards) 



Material. 


AMOUNT. 


PROTEID. 


FAT. 


CARBOHYDRATES. 


Calories. 


Grms. 


Oz. 


Grms. 


Oz. 


Grms. 


Oz. 


Grms. 


Oz. 


Bread 


453-6 

226.8 

226.8 

28.3 

113- 4 
453-6 
28.3 
14.17 


16 

8 
8 
1 

4 
16 

1 
* 


31-75 
34- 02 
12.52 
6.60 
3.63 
18.14 

0.14 


1. 12 
I.20 
O.44 
O.23 
O.I3 
O.64 


2.26 

H-34 
2.04 
7.50 
4-42 

18.14 

12.27 


0.08 
0.40 
0.07 
0.26 
0.16 
0.64 


257-28 

9.60 

4.88 

90.72 

27.36 


4.04 

0-34 
O.I7 
3.20 
O.96 


1,206.82 


Meat 


243-72 
70.OI 
135.42 
75-55 
613.21 
112. 17 
118.62 


Oysters 

Breakfast cocoa. 
Milk 


Broth 


Sugar 


Butter 






Total 






106 . 80 




57-97 




389.84 




2,574.60 



An Ideal Ration of Liquid Food (Mrs. E. H. Richards) 



Material. 



Beef broth or consomme" 

To which has been added one 

large egg, minus shell 

Dried fruit soup 

Lemon jelly 

Whole milk 

Rice or arrowroot 

Grape sugar, or some one of the 

prepared foods (dry) 



Total. 



Amount. 


Proteid. 


Fat. 




Grammes. 


Gr amines. 


I pint. 


20.5 


0-5 


2 oz. 


7.1 


6.8 


1 quart. 

£ pint. 

1 quart. 

3 oz. (dry). 


"b.'s 

34.0 

6.3 


36.0 
o-3 


4 oz. (dry). 


2-5 




2.5 quarts to 
3.0 quarts.* 


76.9 


43-6 



Carbo- 
hydrates. 



Grai 



IOO. O 

12-5 
44.O 
67.2 

100.0 



Calories. 



323-7 



9I.67 
4IO.OO 

77.90 
65I.OO 
304.II 

420.25 



2,043.63 



* According to how the rice is given. 
A Common Invalid Ration too Low in Proteid (Mrs. E. H. Richards) 



1 pint of beef broth or consomme" 

1 pint of dried fruit soup 

1 pint of lemon whey 

1 pint of Imperial Granum, containing 3 oz. 

2 quarts of liquid. Total 



Proteid. 


Fat. 


Carbo- 
hydrates. 

Grammes. 


Grammes. 


Gramtnes. 


20.5 


0.5 


50 


6.8 


21.5 
O.4 


79 
64 


27-3 


22.4 


193 



Calories. 



88.7 
205.O 

521.7 
294.O 

1,109.4 



A Ration Rich in Proteid— 


-after Acute Disease (Mrs. E 


. H. Richards) 


Material. 


Amount. 


Proteid. 


Fat. 


Carbo- 
hydrates. 


Calories. 




Grms. Oz. 
453.6 16 
453.6 16 
453.6 16 
453-6 16 

I4-I7 i 
56.7 2 


Grammes. 

31-75 

64.04 

29.02 

4.60 

O.14 


Grammes. 
2.26 
22.68 
18.OO 

3-25 
12.27 

58.46 
5-84 


Grammes. 

257.28 

39-00 
1. 14 

54-72 
352.14 

35-21 
316.93 


I,205.8l 


Meat 


487.62 




444 • 48 




53-43 


Butter 


118.62 


Sugar 


224-35 










129-55 
12.95 


2,746.12 


Less 10 per cent for indigestibility 




274.61 


Total 




II6.60 


52.62 


2,534.31 









288 



FOOD PREPARATION AND PRESERVATION 



Table compiled by Mrs. E. H. Richards and Miss Marion Talbot 
One day's food, at the University of Chicago, calculated to determine the amounts 
and proportions of the various constituents and their comparison with the general 
average. 



Pounds. 




Per cent 
proteid. 


Per cent 
fat. 


Per cent 

carbo- 
hydrate. 


Pounds 

protein 

net. 


Pounds 
fat net. 


Pounds 
carbo- 
hydrate 
net. 


Calo- 
ries. 


50.O 
9O.O 

45 .0 

4.0 

77.0 

3.o 

192.0 

13.0 

15.0 

15.0 

6.0 


Stew and cold meat. 

White potatoes 

Sweet potatoes 


2I.O 

1.8 

i-5 

34.o 

ii-5 
1.3 

3-5 
3-o 
2.0 


8.0 
0.2 
O.4 

7-5 

1.8 

3-7 
12.0 

83.0 


19. I 
26.O 

70.0 
83.O 

4-7 

3-0 

0.5 

96-5 

65.0 

11. 

19.7 


IO.5 
1.6 
0.7 
1-4 

8.9 


4.0 

O.I8 

0.2 

0.3 
1.4 






17.2 

11. 7 




Flour and grain. . . . 


53-9 
2-5 
9.0 
0.4 




Milk 


6.8 
0.4 
0.3 


7-i 

1.6 

12.5 




Cream 




Butter 






14.5 


Prunes 


3-5 
1.0 

4.85 
12.5 
20.0 
19.0 
15.0 


12.0 

15.0 

5-o 

22.0 


0.2 




4.0 
0.8 
5.o 




9.0 


Oranges, less 20 per 
cent waste 

Bananas, less 50 per 
cent waste 




50.0 

7.2 
41.0 
26.0 


1-3 

0.9 
8.2 
5.0 
2.1 


' ' 0.8 ' ' 
6.2 
i-3 
3-i 
















14.0 


Steak 












657.2 










48.3 
7-9 


38.68 
2.06 


119. 
23.6 




76.0 


(Less turkey, lamb, 
and bread left over) 




















581.2 


Divided by 130. . . . 








40.4 


36.62 


Q5 -4 














4.4 Per nerson. nutrients. 








0.310 

Grammes. 
I26.5 


0.281 

Grammes. 

114. 7 


O.733 












Grammes. 
332.0 


2,946 
2,953 




Daily average for the 
6 months, nutrients 








108.0 


102.0 


381.0 






! 



Average Daily Dietary for an Adult Man (Dujardin-Beaumetz) 

Albuminates 124 grammes. 

Carbohydrates 430 " 

Fat 55 " 

This would correspond with a bread-and-meat ration of — 

White bread , 819 grammes (about 28 oz.). 

Meat 259 " (about 9 oz.). 

As a fair average for computation it may be said that 300 grains 
of nitrogen and 4,800 grains of carbon are daily required. 

In order to obtain the nitrogen necessary for the system from a 
diet composed exclusively of starchy food — as, for example, pota- 
toes — it would be necessary to eat ten pounds. If bread alone is 
eaten, four pounds would be required, and this contains more than 



FOOD CONCENTRATION— CONDENSED FOOD 



289 



twice the amount of carbon needed. About fifteen pounds of cab- 
bage would have to be eaten for the same purpose. On the other 
hand, to obtain sufficient carbon from an exclusive meat diet at least 
six pounds of beef must be consumed. If eggs were used exclu- 
sively, about twenty-three pounds would have to be eaten. An 
ordinary lump of sugar is the food equivalent of an ounce of potato. 
A quart of milk, three fourths of a pound of beef, and five ounces 
of bread are all approximately equal in nutrient value. 



Years of age 

4 8 12 16 20 24 28 32 36 40 44 48 52 56 



64 68 72 76 



;340 



.£260 



£220 

£ 



140 















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Approximate quantity, in grammes, of different classes of foods consumed in twenty- 
four hours, computed according to age. (Mrs. E. H. Richards.) 

The following table from Landois and Stirling is arranged to 
show the total quantity of each single food which it would be neces- 
sary to eat in order to obtain the requisite protein on the one hand 
(column A) and the requisite carbohydrates on the other (column B). 
For the purpose of comparison these authors estimate the necessary 
daily amount of carbohydrates at 448 grammes and the necessary 
proteids at 130 grammes: 



Rice 

Wheat bread 

Lentils 

Peas 

E gg s 

Rye bread. . . 

Cheese 

Potatoes.. . . , 
Beef 



2,562 grammes. 


572 grammes. 


1,444 


625 


491 


806 


582 


819 


968 


902 " 


2,875 


930 " 


388 


2,011 " 


10,000 " 


2,039 " 


614 " 


2,261 " 



29O FOOD PREPARATION AND PRESERVATION 

If a man doing hard labour were to attempt to live upon milk 
alone he would require fully ten pints a day to obtain the carbon 
necessary. Either of these quantities of food greatly overtaxes the 
digestive system. In fact, it would be wholly impossible for most 
people to eat meals of this character. The food would be too heavy ; 
it would take too long a time to consume it, and it would be too 
monotonous. It becomes absolutely essential, therefore, for man to 
so regulate the composition of his diet as to properly balance its 
necessary chemical elements. This balance is best secured by a diet 
in which nitrogen bears the relation to carbon of 1 to 3.5 or 4. In 
bread the proportion of carbon to nitrogen is 3.0 to 1, and in meat it 
is reversed, and stands 1 to 3.5. Munk and Ufflemann state that the 
ratio between animal and plant albumin in the diet should be 3 to 7. 

It is also more economical for the workingman to have fats and 
sugar in his diet and not to live exclusively on meat. The con- 
tractor soon learns that ill-fed men do poor and insufficient work. 
The force must be developed out of the latent energy of matter 
whether bricks are to be carried to the top of a building by a man 
or a hoisting machine. The carbon of coal is oxidised to develop 
force for lifting through the engine. The carbon in all the forms 
of fats, starches, and sugars is utilised in the body of man to enable 
him to do the same work. The labourer does right therefore when 
he eats bacon with his cabbage and treacle with his oatmeal. There 
is one fallacy in the above comparison that must not be overlooked, 
which is that the more fuel the machine consumes, the more work 
it does ; this applies to man only within narrow limits, and too large 
a quantity of food promptly brings him into trouble with his digestive 
organs. (See Overeating.) 

The amount of nutrient material required per diem by a healthy 
adult male doing moderate manual labour is summed up as follows : 



Protein 
Fat 




Atwater. 



125 grammes. 
125 



Carbohydrates 500 " 450 

This proportion is represented by Billings as follows : 

. Lean meat 20 ounces. 

Bread 22 " 

Potatoes 10 " 

Three 'or four cups of coffee. 

According to Chambers, the average adult at ordinary labour 
obtains enough food in a day if he eats one pound of meat and two 
pounds of bread or its equivalent, provided no peculiarities of size, 
health, or climate are to be accounted for. 



FOOD CONCENTRATION— CONDENSED FOOD 29 1 

The average percentage of water in bread is 37 per cent ; in 
cooked meat, 54 per cent ; in vegetables, 70 per cent or more 
(Letheby). 

" Assuming the food average as 23 water-free ounces daily and 
the mean body weight 150 pounds, the body receives yj-g- of its own 
weight in water-free solids. The range in different persons is -^ to 
y^o of the body weight " (Parkes). 

This problem may be differently stated, reckoning in the water 
with the solid food as follows : 

A robust man weighing 144 pounds may consume j% of his body 
weight, or 6 pounds, in nourishment per diem, divided as follows : 

Inorganic food — i. e., water and salts — 3.5 pounds. 

Organic food (animal food, 1 pound; vegetable food, 1.5 pound), 
2.5 pounds. 

It is usually better, unless active exercise is being taken, to eat a 
little less meat and more vegetable food, as previously stated, and 
to drink a little more fluid. 

The average amount of dry food by weight required for breakfast 
may be put at 8 ounces, for luncheon 6 ounces, for dinner 9 ounces. 
The " middle diet " at Guy's Hospital, which is supplied to the ma- 
jority of the patients, furnishes 29.5 ounces of solid food per diem 
in addition to liquids. Of course such persons are taking no active 
exercise. This is equivalent to 17 ounces of dry or water-free food. 
It consists of 4 ounces of meat (cooked), 12 ounces of bread, 8 ounces 
of potatoes, 1 ounce of butter, 0.75 ounce of sugar, 0.25 ounce of 
tea. and 2.5 ounces of milk. 

Nitrogenous material should constitute " one fifth of the water- 
free food, or from 4 to 5 ounces for active life. The ordinary meat 
rations for soldiers is 12 ounces per diem, of which 20 per cent, or 2.4 
ounces, is deducted for waste of bone, tendon, etc. For inactive life, 
from 3 to 3.5 ounces " (Pavy). This diet will completely replace 
the nitrogen eliminated from the body. " Two pounds of bread and 
three fourths of a pound of uncooked beef contain as nearly as possi- 
ble the right proportion of carbon and nitrogen." This makes 44 
ounces of solid food. Water-free meat contains about 0.20 per cent 
nitrogen. 

Fat added to the daily diet in the proportion of about one ounce 
of butter not only supplies necessary force and tissue elements, but 
acts favourably in promoting the proper assimilation of the other 
classes of food and diminishing to a great extent the wear and tear 
of the tissues. With active work, especially in a cold atmosphere, 
more than double this amount is consumed with advantage, and even 
2.5 ounces form an average allowance for many classes of workmen. 

The carbohydrates are required in quantities between 14 and 22 
ounces, their main use being to convey energy for heat and mechan- 
ical work. 



292 FOOD PREPARATION AND PRESERVATION 

The quantity of salts required for daily use varies from 0.5 to 1 T ^ 
ounce. This quantity is less affected by conditions of temperature 
and exercise than are other food constituents. Chaumont estimates 
that a man of 150 pounds can do an average day's work upon a diet 
of albuminoids, 4.5 ounces ; fats, 3.75 ounces ; carbohydrates, 18 
ounces; and salts, iy 1 ^ ounce. These estimates are of water-free 
constituents. 

Water. — The amount of water drunk per diem is usually less than 
should be taken. Many persons believe that it is injurious to drink 
much fluid with their meals and forget to take any between, and 
as a result not enough water is consumed to thoroughly dissolve and 
eliminate the waste matter of the system. The average quantity of 
urine voided is 52 ounces, 10 ounces more are lost from the surface 
of the lungs, and 18 ounces from the skin. This total of 80 ounces 
must be daily replaced to maintain the equilibrium of the body. 
The solid food of a mixed diet has been shown above to contain 
on the average 50 or 60 per cent of water, so that about 25 ounces 
of water are taken into the system daily as an integral part of the 
food. In addition, at least 55 ounces or more should be drunk either 
as plain water or in various beverages. 

Another way of stating the above facts is that the average quan- 
tity of solid food (not water-free) which is required by adults is 
between 40 and 45 ounces per diem, and the total amount of food, 
including all fluids, should be from 95 to 120 ounces, of which three 
fifths or four fifths is composed of water, and the remaining one 
or two fifths of water-free substance. These estimates are only 
intended for general application, and there are necessarily many 
exceptions. 

The ratio of solid to liquid food varies in health with the greater 
or less preponderance of fluids, the solid being more constant. It is 
commonly nearly 1 to 2, but many persons reduce it to 1 to 1.5, or 
even 1 to 1. 

Muscular exertion demands an increase in both solid and fluid 
food, but the former is more essential than the latter, if the exertion 
be prolonged. 

When a man does increasing work, unless his food be proportion- 
ately increased, he begins to consume his own tissues until their loss 
so weakens him that he is obliged to desist from a part, at least, of 
his labour. Should the disproportion between output and income 
continue, he becomes so enfeebled as to be liable to the inroads of 
hardship in various forms — especially those of cold and zymotic 
diseases. 

It is estimated that in each twenty-four hours a man of normal 
health and physique absorbs, including the respiratory oxygen and 
water, about 7.25 pounds of material, which he eliminates in a corre- 
sponding quantity of waste, about three fifths of which is water. 



FOOD CONCENTRATION— CONDENSED FOOD 293 

One of the best means of determining the proper amount of food 
to sustain a man in good health is derived from a study of the ex- 
periences of arctic explorers. Their men are subjected to great 
hardships and feats of endurance, as well as to intense cold. From 
the nature of the expeditions no superfluous food can be carried, and 
yet the chief factor in success is the maintenance of good bodily 
vigour. For these reasons the rations for arctic travellers have been 
most carefully established, and a brief review of them will throw 
much light upon this interesting subject. 

The Peary expedition to the north pole in 1887 used 19 ounces 
of solid food as the ration for the sledging expedition, but this soon 
proved to be inadequate in the cold of the arctic regions. Dr. Ray 
used 29 ounces, which also proved insufficient, and later 34 ounces 
of solid food. Various other expeditions have used 32 ounces 
of solid food, consisting wholly of pemmican, which has been 
sufficient. 

Molintock, another arctic sledge traveller, used 40 to 48 ounces 
of food daily. Captain Neary's expedition used 38 ounces of 
solid food, proportioned as follows : Meat, 20 ounces ; biscuits, 
14 ounces; potatoes, 2 ounces; sugar, 2 ounces. To this were 
added chocolate, 1 ounce; rum, 2 ounces; and 1.5 ounce each 
of tea and tobacco with condiments, making in all 44 ounces of 
supplies. 

De Long quotes from the physician to his arctic expedition that 
" alcohol proves a great advantage, keeps off the craving for food, 
preventing gnawing at the stomach, and has kept up the strength 
of the men as given — 3 ounces per day." (This was during starva- 
tion, but, as stated on p. 233, alcohol is injurious to the mainte- 
nance of robust health in cold climates.) 

While performing active exercise in the cold a diet of 1.5 pound 
of stewed deer's meat did not prevent hunger, but 1.5 pound of 
pemmican per diem, with one half ounce of tea and one half ounce 
of Liebig's extract of meat, supported life for some time. On leaving 
the ship and starting on their long sledge expedition, the following 
daily ration was allowed each man by Lieutenant De Long : 

Breakfast 

Pemmican 4 ounces. 

Ham 1 ounce. 

Bread 3 " pieces." 

Coffee 2 ounces. 

Sugar $ ounce. 

Dinner 

Pemmican 8 ounces. 

Liebig's extract , 1 ounce. 

Tea i " 

Sugar $■ " 



294 FOOD PREPARATION AND PRESERVATION 

Supper 

Pemmican 4 ounces. 

Tongue 1 ounce. 

Tea \ " 

Sugar £ " 

Lime juice 1 " 

Bread 4 ounces. 

While held fast in the ice, and still on the steamer, the average 
allowance of food per day was about four pounds, but some com- 
plained of being hungry on this ration. Several men suffered 
severely from lead poisoning from the solder used in canning toma- 
toes, traces of lead being found on examining the contents of the 
can. The acid of the tomato acts upon the solder, forming a soluble 
lead salt. The cans, however, had been kept for a period of two 
years before their contents were eaten (De Long). (See Canning, 
p. 280.) 

In the voyage of the Jeannette to the arctic zone in the polar 
expedition of 1879-81 a very liberal diet was allowed the sailors on 
entering the arctic regions, the average quantity of food allotted per 
man per diem being a ration of 5.5 pounds. Meat was furnished 
three times a day. Fat was supplied in the form of pork and butter, 
and bread and potatoes made the bulk of the starchy diet, constitut- 
ing about two thirds of the whole amount of food. The diet at first 
included large quantities of condensed milk, butter, eggs, oatmeal, 
cheese, and macaroni, together with a great variety of canned fruits 
and vegetables and dried fruits, such as apples, peaches, dates, figs, 
prunes, and raisins. 

In Lieutenant A. W. Greely's account of the expedition (Three 
Years of Arctic Service) he says : " The amount of food per man 
each day actually eaten in over two years at Fort Conger was as 
follows : 

Meat 26 . 8 ounces. 

Canned vegetables 10 . o 

Sugar and sirup 5.3 

Farinaceous articles 13.6 

Canned fruits 4.7 

Dried fruits, preserves, fruit, butter, and pickles 2.9 

" This aggregate of 64.3 ounces would doubtless be increased 
by coffee, chocolate, tea, spices, condiments, etc., to nearly seventy 
ounces. This amount may reasonably be assumed as the quantity 
of food necessary for the maintenance of a man's health in a lati- 
tude such as Conger (81 ° 44' N.), where the actual temperature is 
4 F. (20° C.)." He adds that tomatoes proved to be the most serv- 
iceable vegetable, and apples and peaches the best fruits. The bev- 
erages consisted of coffee, tea, chocolate, cider, and a small quantity 
of rum, the latter averaging two gills weekly for each man, which he 



FOOD CONCENTRATION— CONDENSED FOOD 295 

regarded as beneficial from the effect it had upon the cheerfulness 
and good humour of the men. Meat in the above table included fat, 
in the shape of pemmican (four ounces), butter, lard, pork, and 
bacon. 

The hours for meals were as follows : Breakfast, 7 A. m. Dinner, 
4 p. m., and two lunches. The latter consisted of hard bread and 
butter, tea and coffee. The typical menu was as follows : 

Breakfast. — Corn beef, oatmeal, fresh bread, chocolate, or 
coffee. 

Dinner. — Vegetable soup, baked pork and beans, corn bread, 
stewed peaches, and coffee. 

On sledging expeditions it was important to reduce the weight 
and bulk of the food to a minimum ; accordingly in the Greely ex- 
pedition of 1882 the daily allowance for sledging expeditions was 
thirty-nine ounces, to which was added an ounce of lime juice. The 
lime juice was carried solidified in the form of small squares, in 
which form it proved refreshing and invigorating to the exhausted 
men. This constituted the ration of the first year, 1882. Greely 
writes ; z 

" On the above ration of 1882 parties kept the field for forty 
days in a mean temperature below zero 17.8 C, and returned in 
health and strength." 

In 1883 the experience of the previous year led him to modify 
the ration by replacing part of the bread with butter and meat. This 
modified ration consisted of — 

Meat 22 ounces. 

Butter 2 " 

Vegetables 4 " 

Bread 10 " 

Sugar 2 .. " 

Milk \ ounce. 

Tea or chocolate 1 " 

Salt , i " . 

Pepper uV " 

with an allowance of six ounces of alcohol for cooking the food of 
a party of three or four people ; therefore the ration contained 
40.5 ounces besides beverages. Greely says again : " Three fourths 
of the ration were about equal quantities of pemmican, bacon, and 
frozen musk-ox meat, while the balance was made up of canned sau- 
sages and corned beef in about equal quantities " (Three Years of 
Arctic Service, vol. i, pp. 202, 203). He suggests as a still further 
improvement that the vegetable ration should consist of three ounces 
of preserved potatoes, the remaining ounce being replaced by half 
an ounce each of milk and extract of beef tea, which is the best 
drink for the arctic regions. It should be chiefly used in the field 
in the form of an extract. A little coffee is preferable to chocolate. 
21 



296 FOOD PREPARATION AND PRESERVATION 

The latter was found to induce thirst during the day. Tea should 
be compressed or used as an extract. Curry paste and other power- 
ful condiments were also found serviceable. Alcohol was not con- 
sidered necessary as a food. 

During the third winter of his arctic expedition, from November 
1, 1883, to June 23, 1884, Greely's per capita ration for his entire 
party was : 



Meat 4.0 ounces. 

Beef extract o . 26 ounce. 

Evaporated potato 0.4 " 

Soup 0.6 " 

Tomatoes 0.3 " 



Butter 0.5 ounce. 

Lard 0.26 " 

Rice 0.1 " 

Raisins o. 16 " 

Tea, compressed 0.3 " 



Peas 0.2 •' I Extract of coffee o . 44 



Corn 0.2 " 

Carrots o. 1 " 

Bread 6.0 ounces. 

Dog biscuit 0.8 ounce. 



Extract of chocolate 0.3 

Milk 0.2 

Mulberries 0.2 



It is noticeable that alcohol is omitted from this ration. C. E. 
Borchgrevink (First on the Antarctic Continent, 1898-1900) made 
extensive use of dried vegetables, and such articles as ham, bacon, 
curry and rice, cheese, dried fish, sardines, jam, marmalade, and 
cocoa. 

The usual estimate for the total quantity of all food material, 
including solids, water, and respiratory oxygen as well, which is 
consumed by a healthy adult male per annum is one and a half ton. 

Following is the estimate of total food supply for eighteen 
months for one man in the Yukon region. The total weight, about 
one ton, is considerably less than that of food ordinarily eaten, owing 
to the fact that fruit and vegetables must be carried in an evaporated 
condition. 

" The chief items are 600 pounds of flour, 300 pounds of bacon, 
150 pounds each of beans and sugar, 75 pounds each of rolled oats 
or other mush material and cornmeal, 50 pounds of rice, six dozen 
cans of condensed milk, 35 pounds of butter in sealed cans, 150 
pounds of evaporated vegetables, 100 pounds of evaporated fruit, 
50 pounds of prunes and raisins, 30 pounds of dried fish, 40 pounds 
of coffee, with baking powder, soda, salt, pepper, ginger, mustard, 
yeast cakes, tea, soap, matches, lime juice (very important), dried 
beef, extract of beef, soups in tins, sausage, tobacco, etc., as desired, 
bearing in mind always that variety of food promotes health. There 
has been more or less said in the newspapers about various con- 
centrated foods, but, with the exception of evaporated vegetables 
and fruit, condensed preserves, condensed milk, and beef extract, 
nothing yet has been brought forward which has been proved de- 
sirable. One cannot afford to experiment with his stomach in 
Alaska." (New York Evening Post, July 6, 1898.) 



FOOD CONCENTRATION— CONDENSED FOOD 297 

Men eat about two thirds of all the meat, and women one third. 
Men consume about four fifths of all the alcoholic beverages, and 
women one fifth. The latter consume much more tea than men. 

Soyer has computed tables of the total quantity of foods con- 
sumed by a man during his lifetime. He estimates that a man during 
sixty years of life after early childhood eats 33J tons of meat, vege- 
tables, and farinaceous food, and that an ordinary man by the time 
he has attained to seventy years has consumed 30 oxen, 200 sheep, 
100 calves, 200 lambs, 50 pigs, 1,200 fowls, 300 turkeys, 24,000 eggs, 
4.5 tons of bread, and 3,000 gallons of tea and coffee. 

Starvation and Inanition 

Starvation, or asitia, is a term which technically applies rather to 
the lack of sufficient food for the maintenance of the body, while 
inanition means the lack of assimilation of food by the tissues. 
Where there is defective absorption, food may be furnished to the 
system in abundant quantity, but inanition results from lack of abil- 
ity to absorb and develop force and nutriment from it. The interval 
through which different persons can subsist without food depends 
upon: 1, External conditions of temperature and moisture; 2, the 
amount of work being performed ; and 3, the existing condition of 
the body. 

1. The maintenance of a uniform warm external temperature 
prolongs the period through which man can endure abstinence from 
food. Exposure to cold accelerates starvation symptoms by reduc- 
ing the vitality of the body and the resistance of the system. Mois- 
ture in the air, by preventing evaporation from the surface of the 
body, prolongs the period of starvation which can be endured. 

2. Persons who refrain completely from exercise can live far 
longer without food than when undergoing active work. Self-for- 
getfulness in times of famine, by diverting the mind from the suf- 
ferings of the body, tends to prolong life. 

3. Well-nourished persons can endure longer intervals of absti- 
nence from food than the weak or diseased. The distress of deliri- 
ous or apparently insensible persons may be augmented by lack of 
sufficient food. Sex has no influence with the effects of starvation, 
but they are most keenly felt at the extremes of age, by young 
children, and senile subjects. 

Those who have the most fat stored in their tissues call upon this 
supply to maintain the energy of the body in the absence of food, 
and, having a larger supply than thin or emaciated persons, they can 
endure starvation much longer, although they may complain more 
bitterly of the pangs of hunger than invalids, who are accustomed 
to a low diet. Chossat's experiments with starving animals proved 
that while they lost 40 per cent of body weight, the loss of fat alone 



298 FOOD PREPARATION AND PRESERVATION 

reached 90 per cent, being greatly in excess of that of any other 
substance. Anselmier fed starved dogs upon their own blood, and 
succeeded in thus prolonging their lives for three or four days be- 
yond the usual limit, and life lasted until 60 instead of 40 per cent 
of their body weight had been lost. 

When food is wholly withheld, life cannot be prolonged beyond 
six to ten days in the majority of instances. During the winter of 
i876-'77 an accident occurred in a colliery in South Wales by which 
four men and a boy became imprisoned for ten days without food. 
At the expiration of this period they were found alive, and, although 
very feeble, they were able to walk when released. They had had 
a supply of water, and the atmosphere in which they were confined 
was moist. At another colliery accident in Wales a number of 
men were confined in a mine for six days without food, and, al- 
though their sufferings were extreme, nearly all were able to walk 
out on being rescued. As a result of an earthquake in Calabria, 
Sicily, in 1783, several persons were imprisoned in falling ruins. A 
girl of eleven years survived, having been six days without food, 
and another girl of sixteen years survived after eleven days of star- 
vation. 

The lack of food may be endured with far less torture if water is 
applied in abundance to the system. When water is withheld in 
addition the body loses weight much more rapidly, the tissues be- 
come dry, the thirst excessive, the secretions are suppressed, and 
the suffering is greatly intensified. 

VOLUNTARY FASTING 

Of late years several persons have attempted prolonged feats of 
starvation, tempted by love of notoriety or desire of gain, by ex- 
hibiting themselves for the gratification of public curiosity. In sev- 
eral instances they have been carefully watched by medical experts 
and there is every reason to believe that the fast has been conducted 
with honesty. In at least two of these authenticated instances, those 
of Tanner and Succi, the complete starvation period has been pro- 
longed' for over forty days. In both cases fluids were allowed, and 
one of the men relieved intense epigastric pain and food craving by 
condensed medication. 

Succi was an Italian who, in 1890, undertook an absolute fast of 
forty-five days, during which period he lost 42J pounds and drank 
1,154 ounces of water, or an average of about 25^ ounces per diem. 
This he took in the forms of plain water, mineral water, and ice. 
He became alarmingly emaciated during the fast, but even on the 
last day had strength to walk about the room. He resumed eating 
by first taking cocoa, and subsequently bouillon and other light 
articles', and made a complete recovery. His mind remained clear 



FOOD CONCENTRATION— CONDENSED FOOD 299 

throughout. He took occasional doses of a few drops of an elixir 
supposed to contain opium. 

There have been a number of cases from time to time recorded 
of " fasting girls." They are usually of nervous hysterical tempera- 
ment. On reaching the age of puberty they become dyspeptic and 
grow shy and disinclined to eat what is good for them, although 
they may gratify abnormal cravings surreptitiously. They are very 
apt to be at the same time strongly impressed by religious beliefs, 
and in their disordered mental condition to acquire the delusion 
that it is sinful to eat. This delusion becomes fixed, and they then 
are regarded as " freaks " and achieve much newspaper advertising. 
They should be treated as ordinary cases of hysteria simply, and be 
removed from oversympathetic friends and dealt with kindly but 
firmly. Hydrotherapy yields excellent results, and even a good 
spanking may not be amiss in awaking the patient to a realising 
sense of her errors. The claim sometimes made in such cases as 
those just described, that they lose no weight, is nonsensical, for 
the body must diminish in weight continually by evaporation of 
water from the lungs and skin and its passage from the kidneys and 
by the exhalation of carbon. Edward Smith estimates that the 
quantity of carbon exhaled in one day of fasting is equivalent to 
that contained in twenty ounces of bread. 

When either voluntary or forced starvation takes place very 
gradually, especially in elderly people, their systems become slowly 
accustomed to very small quantities of food. 

Luigi Cornaro was a Venetian gentleman who advocated a very 
abstemious diet, and whose own case is often cited in illustration of 
the smallest quantity of food which may support life. He was born 
in 1463 ; after a reckless and intemperate youth he reformed, and 
by careful dieting prolonged his life to one hundred and three years. 
He published a Treatise on a Temperate Life, and for the last forty- 
eight years of his own existence he subsisted on a daily allowance 
of twelve ounces of vegetable food with fourteen ounces of light 
wine. He occasionally ate eggs, but rarely took any other form 
of animal food. 

There is much wisdom in some of his doctrines, but, unfortu- 
nately, no one else who has attempted to practise his rules has met 
with similar success in prolonging life. The majority of mankind 
would undoubtedly prefer to live fewer years for the pleasure of 
being less abstemious. 

Periods of voluntary fasting of greater or less duration are rec- 
ommended and practised by devotees of many religious sects. Such 
fasting was formerly carried to a greater extent by ascetics than at 
the present time. As a means of mental discipline or cultivation of 
will power, fasting may in some instances be defended, but fasting 
" to be useful must be voluntary " (Chambers), otherwise it is apt 



300 FOOD PREPARATION AND PRESERVATION 

to cause irritability of temper, and it may even lead to deception to 
obtain food. Such fasting may be carried to an excessive and in- 
jurious degree unless it be definitely limited and supervised. It is 
more powerful in its effect, moreover, if it is but seldom undertaken. 
If a man so reduces himself by fasting that he cannot use his in- 
tellectual faculties with accustomed vigour he may be sure that he 
is doing himself injury. Better than complete fasting for purposes 
of mental discipline or religious motives is the temporary elimination 
from the diet of accustomed luxuries, or giving up such articles of 
daily use as butter, sugar, salt, wine, tobacco, etc. This, in fact, is 
a custom practised by many persons during the Lenten season. 

The day has long since passed when lasting can be regarded as 
favouring either clearness of intellect, muscular strength, or en- 
durance, and, as Gerland has said, " the ethnologist can trace the 
physical and mental decay of whole nations to a long course of insuf- 
ficient food." 

Dr. Denis, of Brussels University, presented an interesting report 
at the International Congress of Anthropology for 1892, showing 
striking parallelism in the curves of famine and crime, and of mar- 
riages as inversely related to the price of wheat. 

Symptoms. — The symptoms which result from complete starva- 
tion are characteristic. If food is suddenly withheld, the sensation 
of hunger gradually increases at first, becomes extreme, lasts for two 
or three days, and slowly disappears. It is accompanied by a gnaw- 
ing pain in the epigastrium, which is relieved on pressure. The pain 
may disappear with the hunger, but it is followed by a sensation of 
extreme weakness or faintness, which is both local in the stomach 
and general throughout the body. The sensation of thirst, on the 
contrary, when all fluid is withheld, persists until death or until the 
subject becomes insane or unconscious. 

When food is gradually withheld, urgent hunger may not be felt 
at all, but the longer and more severe the fast, the more difficult 
does digestion become. The circulation grows feeble, the heart 
action rapid, the respiration shallow and possibly slow and irregular. 
There is apt to be some thirst, even though water be supplied. If 
it be withheld, the torture becomes unbearable. Constipation may 
be succeeded by diarrhoea, but it more often remains complete. The 
facies are typical, the expression is anxious and staring, the orbital 
fat disappears, and the eyes are greatly sunken and finally become 
glassy. Corneal ulceration may be present. General bodily ema- 
ciation ensues, the muscles are soft and reduced in size by more 
than one half, and the abdominal viscera to a similar degree, the 
skin becomes pale, loose, and, from change in the secretion of per- 
spiration, emits a peculiar fcetor and acquires a clay-like colour. 
The feet and ankles may swell, owing to the enfeebled circulation. 

The victims become so ravenous that all sense of taste gives place 



FOOD CONCENTRATION— CONDENSED FOOD 3OI 

to the intense hunger. Upon one of the recent unfortunate arctic 
expeditions, on one occasion, the tea being accidentally omitted from 
the kettle, dirty water was drunk by the starving men without rec- 
ognising the difference. The secretions are altered, and become 
inactive. The urea excretion falls to one fourth the normal. The 
total volume of blood is diminished, and anaemia is extreme. 

The body temperature begins to fall in the first day of the period 
of starvation, and continues falling, so that a loss of ten or more 
degrees below the normal of 98.6 F. may occur. 

In extreme cases muscular action is no longer possible ; there 
are vertigo and faintness on raising the head, the voice is lost, and 
gradually the nervous system succumbs to languor and general 
prostration ; the mind becomes more and more dull, listless, and 
even idiotic, the victim being unable to describe his condition or 
express his wants. He may have hallucinations, insomnia, and 
dreams, in which are often pictured scenes of plenty. 

The sufferings produced by slow starvation distract the mind 
and render connected thought difficult. If long continued, the mind 
becomes unbalanced, and men who have been shipwrecked and left 
to wander in the open sea in rowboats for a long time without food 
usually become delirious, or even maniacal, within four or five days. 

In 1874 three men and two boys were castaway for twenty-two 
days in an open boat. They had at first ten days' provisions, and 
subsequently nothing but old boots and jellyfish, and they fought 
violently with each other in the delirium which ensued (Chambers). 

During prolonged starvation the most important organs of the 
body are nourished at the expense of others, especially of the skeletal 
muscles. For example, in an animal starved for thirteen consecutive 
days it was found that while the muscles lost 30 per cent in weight, 
the brain lost but 3 per cent and the heart but 2.5 per cent. 

The ultimate effects of starvation are identical whether the pro- 
cess be gradual or rapid, occupying days or years, and death results 
when the body has lost six tenths of its weight. It may occur while 
the victim is in stupor or coma from cardiac failure or, possibly, in 
convulsion. The actual cause of death has by many been attributed 
to the loss of body heat. While this is undoubtedly a contributing 
factor, it is more reasonable to suppose that it is due to the general 
inanition of the muscles and nerves and the progressive enfeeble- 
ment of the heart action. The heart muscle not infrequently will 
be found to have undergone fatty degeneration. It is, however, true 
that in animals kept warm by artificial means the advent of death 
from starvation may be considerably postponed. 

While undergoing starvation the blood is reduced in volume pro- 
portionately with the loss in body weight, but it nevertheless main- 
tains the balance of its normal average composition (Panum and 
Voit). 



302 FOOD PREPARATION AND PRESERVATION 

Hunger is not always a reliable guide as to the need of the sys- 
tem for food. Some dyspeptics are always hungry and eat more 
than they can digest. Hunger begets a habit of too rapid eating, 
and more food may be taken than is necessary, because it has not 
had time to be absorbed and reach the tissues before the meal is 
over. Moreover, hunger may be temporarily appeased by eating 
other substances than food, like bits of old leather, for example, 
which appear to act mechanically in the stomach. For this purpose 
men rendered insane by hunger will sometimes swallow all manner 
of useless and harmful substances, such as buttons, pieces of metal, 
pebbles, etc. 

No more graphic and pathetic account of the miseries of starva- 
tion exists than is found in the journal of Lieutenant De Long, 
commanding the expedition of the Jeannette, which visited the arctic 
regions in i879~ , 8i (The Voyage of the Jeannette, Journals of 
George W. De Long, 1883). After leaving their sinking vessel the 
members of the expedition were exposed, at first in open boats, and 
later in their long sledge journey, to the most exhausting work and 
to intense suffering from cold and wet. They frequently dragged 
their sleds in severe storms for ten or twelve miles a day, while 
subsisting solely upon half a pound of stewed deer meat, with a 
little tea three times a day. This food being exhausted, they were 
obliged to consume the meat of their fast remaining dog, which they 
ate fried. They subsisted upon this food exclusively for four days 
longer, having an allowance of but half a pound a day, and finally 
their last journey of twenty-five miles was performed with no other 
nourishment than a few ounces of alcohol and an infusion made 
from some old tea leaves. During this time their intense suffering 
from hunger was partially alleviated by chewing scraps of deer 
skin, which, from its bulk in the stomach, seemed to afford slight 
relief. 

The alcohol being exhausted, they lived for another day upon 
a teaspoonful of olive oil, with a breakfast composed of an infusion 
made from the arctic willow (containing really no nourishment) 
and " two old boots." After this the men, becoming weaker and 
weaker, -were unable to proceed farther on their journey, being 
driven back by intense cold and the difficulty of crossing the par- 
tially unfrozen rivers. Their feebleness gradually overcame them, 
until one by one they died of inanition. Four men survived for 
sixteen days upon absolutely no food whatever, and possibly their 
sufferings were even further prolonged, but the journal of their gal- 
lant and heroic commander ceased at this point, for he, too, died. 

In the starvation which overtook the members of the Greely 
party on the Lady Franklin Bay Expedition, and caused the death 
of a large number of the company, attempts were made, as in the 
case of the Jeannette expedition, to relieve the agonies of hunger 



FOOD CONCENTRATION— CONDENSED FOOD 303 

by filling the stomach with indigestible material of various kinds. 
The skin sleeping bags were roasted or boiled and eaten, and even 
oil-tanned skin was consumed, while the sufferings of the men were 
aggravated by the presence of game in sight but out of reach. A 
few shrimp and lichens were obtained and stewed with seal skin. At 
this time, although it was summer, the temperature was occasionallv 
below the freezing point, but during part of the two years spent in 
the vicinity of Fort Conger it was sometimes — 40 or even — 6o° F. 

During the siege of Paris in 1871, when thousands of the in- 
habitants were reduced to starvation, it was found that a diet which 
was barely sufficient to support life consisted of ten ounces of bread 
with one ounce of meat. 

In prisons the diet limit has often been reduced too low. It 
may be sufficient to maintain life, but if hard labour be inflicted, 
weakness, sickness, and death will inevitably follow. In an over- 
crowded prison a daily ration of twenty-eight ounces of unbolted 
meal and five ounces of bacon has been known to cause death by 
slow starvation. As a means of discipline a starvation diet is some- 
times enforced in penal institutions for a few days, and it is usually 
quite as efficacious as corporal punishment. A diet which is de- 
signed to effect its aim by monotony as well as reduction in quan- 
tity, but without reaching the limit of cruelty, is the following, 
which has been used at the United States military prison at Fort 
Leavenworth : 

Breakfast. — Hash or stew, 8 ounces ; bread, 7.5 ounces. 

Dinner. — Soup, 8 ounces ; bread, 7.5 ounces. 

After twenty continuous days of this diet eight ounces of bread 
are allowed for supper. This diet has been found to make the most 
refractory men soon manageable. (See Diet in Prisons.) 

Treatment. — The treatment of persons rescued from starvation 
must be conducted with the utmost care. The digestive system is 
so enfeebled that to allow them to yield to the cravings of returning 
appetite is to insure immediate death by overburdening the stomach 
and circulation. The body should be kept warm and in absolute 
rest, and warm fluid nourishment in minute quantities — half tea- 
spoonful doses of beef peptones or meat juice — may be given at 
intervals of fifteen minutes or half an hour. If no vomiting or evil 
symptom results, small quantities of peptonised milk may be tried 
at half-hour intervals. Alcoholic stimulants in any quantity are to 
be avoided, but a few drops of brandy or whisky may be given from 
time to time in water. If the stomach is irritable, nutrient enemata 
should be employed. The following day the quantity of food may 
be slightly increased, but if emaciation is extreme and enfeeblement 
is pronounced, the patient must be kept upon a fluid diet for ten 
days or more. Easily digested forms of starchy food may then be 
added, such as dry bread, arrowroot, gruel, and the like. 



304 FOOD PREPARATION AND PRESERVATION 



FAMINE 

When starvation occurs upon a large scale, affecting a commu- 
nity with famine, pestilence is sure to accompany it. Disease has 
always been rampant in Ireland when the potato crops have failed, 
and in India when the grain supply has given out. Much of the ill- 
ness which occurred in the early history of the Crimea was due to 
insufficient food, and in the Middle Ages the ravages of pestilential 
diseases, such as typhus, smallpox, the plague, etc., were always 
worst in times of general starvation. The history of epochs of 
famine in siege or otherwise is always accompanied by outbreaks 
of violence, for hunger begets ill-temper, vice, and crime. This has 
occurred of late years, notably in Athens, Florence, and London, 
and in Paris during the Commune. 

Nothing predisposes man so much to all forms of infectious 
disease as starvation and inanition. This is so well known that 
physicians and nurses in charge of contagious cases are particularly 
cautioned to eat well and not expose themselves to infection while 
suffering from fatigue and lack of food. 

Improperly Balanced Ingredients of Diet 

Improper diet is often quite as injurious as slow starvation, for a 
person who eats a large bulk of food of one class, to the exclusion 
of other classes, may delude himself by thinking that he is taking 
nourishment enough on account of the degree of satiety which he 
derives from his diet. " The outward appearance of such persons is 
to a certain extent characteristic, marked generally by a pale and 
puffy aspect, due partly to a general excess of water in the tissues 
and partly to an abnormal deposition of fat " (Bauer). The evil 
result of such diet is very apparent among infants and growing 
children who have been fed upon a large bulk of farinaceous food to 
the exclusion of milk, meat juice, etc., and in them the foundation 
may be laid for the development of scurvy, or scrofula, or tuberculo- 
sis, and sometimes also the stomach and bowels become permanently 
distended. (See Diet for Infants and Children.) 

The effects above described are commonly produced by excessive 
ingestion of starchy and saccharine foods to the exclusion of pro- 
tein, and, on account of the cheaper cost, the children of the poor 
are more apt to be injured in this manner than the rich, among 
whom the opposite diet — an excess of nitrogenous aliments — is more 
common. The latter sometimes gives rise to circulatory disturb- 
ances, overworks the kidneys, and produces nervous irritability. 

It has often been observed by dietists that proportionately more 
fat is consumed in the United States than in Europe, and some are 
inclined to attribute to this form of food some influence upon the 



FOOD CONCENTRATION— CONDENSED FOOD 



305 



greater activity which characterises Americans. It is extremely 
doubtful whether this has as much to do with it as climatic and 
other conditions of environment. 

Taken by themselves, carbohydrates have little or no effect in 
deferring death from starvation, but with albuminates they act as 
tissue sparers. (See Force-producing Value of Foods, p. 21.) 

Mrs. Richards gives the following useful comparisons of food 
composition, showing particularly the inefficiency of fluid diets other 
than milk to support life : 



Three quarts of milk 

Three quarts of beef broth or consommi 

Soup of Munich Hospital 

Rations recommended in certain invalid re- 
ceipt books 

Rations recommended in another receipt book 

Prausnitz's estimate of normal ration for man 

Prausnitz's estimate of normal ration for 
woman 

Estimated life ration 

Maximum work ration 

Minimum work ration 



Proteid. 



I02.0 

I23.O 

21.6 

24.5 
66.5 

IIO.O 
IOO. o 

75.0 

125.0 

IIO.O 



Common invalid ration too low in protein . 
1 pint beef juice, containing 7 per cent. . . . 
1 pint whole milk 

1 quart flour gruel, made with whole milk. 

2 quarts of liquid. Total 



31.5 
17.0 

18.2 



66.7 



Fat. 



I08.0 

3.0 

21.6 

28.5 

23-5 
50.0 

50.0 

40.0 

125.0 

90.0 



18.0 

18.2 



36.2 



Carbo- 
hydrate. 



I32.O 

I08.O 

65.6 

83.5 

350-400 

3OO-350 
325-0 
450.0 
420.0 



22.0 
38.0 



60.O 



Calories. 



1,953.0 

532.0 
730.0 

631.O 

83I.O 
2,350.0 

2,100.0 
2,000 . 

3,500.0 
3,000.0 



I29.O 

325-5 
397-9 



852.4 



PART IV 
FOODS REQUIRED FOR SPECIAL CONDITIONS 



AGE AND FOOD. 
INDIVIDUAL SIZE AND FOOD. 
BODY WEIGHT AND FOOD. 
SEX AND FOOD. 



DIET AND HEREDITY. 
DIET AND RACE. 
CLIMATE AND SEASON 
FOOD. 



an: 



AGE AND FOOD 

Food in Childhood 

A child at three or four years of age actually consumes nearly 
one fourth as much food as it requires at adult life, for during this 
process tissue growth is very rapid, and if the child be in health, 
the bodily activity is relatively very great. An active child at twelve 
or fifteen years of age who is growing fast and who is freely exer- 
cising may require and assimilate as much food as a man past middle 
age, and insufficient food and food of defective quality and composi- 
tion work proportionately far more harm during the growing age. 

Inquiries made in this country in regard to the diet of older 
children and young adults demonstrate that it contains a propor- 
tionately large quantity of fatty food — much more than is custom- 
arily consumed in European countries. This is in great part owing 
to the habit of eating considerable butter, which, generally speaking, 
the better circumstances of Americans enable them to obtain. 

The following table from the investigations of the Munich School 
gives : 

The Minimum Amount of Food Necessary for Different Ages 



Age. 



Infant until one and a half year 
Child from six to fifteen years. . 

Man (moderate work) 

Woman 

Aged man 

Aged woman 

306 



Nitrogenous 
substances. 



Grammes. 

20-36 

70-80 

Il8 

92 

IOO 

80 



Fats. 



Grammes. 

30-45 

37-50 

56 

44 
68 
50 



Carbohydrates. 



Grammes. 

60-90 
250-4OO 

500 

400 

350 

260 



AGE AND FOOD 307 

The special diet regulations for infancy and childhood are de- 
scribed at length under the headings Diet in Infancy and Diet in 
Childhood. 

Food in Adult Life 

The nature and quality of the diet appropriate for adults must 
depend somewhat upon individual constitution, occupation, habits 
of life, and to some extent upon the climate in which they live. 

The full adult weight is not usually attained before the twenty- 
fifth year, although in some cases it is reached earlier. In many 
instances adults after the age of forty or forty-five years increase 
considerably in weight. In men the bones continue to solidify until 
about the thirtieth year ; in women this condition is usually reached 
a few years earlier. When the final growth of the body and develop- 
ment of the vital organs is completed the use of food consists simply 
in maintaining the proper equilibrium of the tissues by replacing 
waste with new material and in furnishing fuel for the development 
of force, the food being no longer required for growth. Many per- 
sons eat more than is required for these purposes. 

As men advance in life, become prosperous, and acquire more 
and more luxurious habits of living or become absorbed in various 
occupations, they are apt to take less exercise, while the number of 
luxuries of the table which their means enable them to command 
constantly tempt them to indulge in food which is not needed and 
which is imperfectly consumed in the body. 

Sir H. Thompson writes (Diet in Relation to Age and Activity) : 

" More than one half of the disease which embitters the middle 
and latter part of life among the middle and upper classes of the 
population is due to avoidable errors in diet." 

It is often difficult for a man between the ages of twenty and 
thirty years who has led an exceptionally active and vigorous or 
perhaps even an athletic life to realise, as he grows older and passes 
on towards forty-five or fifty years of age, that he requires less food 
to maintain his organic equilibrium than formerly, and his habits of 
eating acquired at a more impressionable period of life cling with 
great pertinacity. It may prove an advantage sometimes in such 
cases to lessen the appetite for dinner by a late lunch, or to try 
other simple means of restriction. 

These observations fail of application to the poor, whose means 
do not allow them to gratify their appetites, and in the case of those 
whose diet is established for them. There is quite as much, if not 
more, ill arising from deficient feeding as from overfeeding; in either 
case the difficulty is only made serious by long continuance, and 
occasional great indulgence in overeating as in overdrinking is less 
productive of harm than habitual indiscretions of a lesser degree. 
So much is due to habit in the different organs of the body in 



308 FOODS REQUIRED FOR SPECIAL CONDITIONS 

relation to food that the stomach and intestine will usually reject 
undigested the contents of an occasional excessive meal, whereas 
with habitual overeating they become accustomed to appropriating 
very large quantities of food, which are absorbed, but which are not 
eliminated without straining the excretory organs, or which may be 
stored in the body in the form of incompletely oxidised material, 
which accumulates until the system rebels and a violent bilious 
attack by vomiting and purging relieves the overburdened body. 
There are persons who have so little restraint over their appetites 
that they persistently indulge themselves in this way. 

Food in Old Age 

In old age there are inevitable changes which slowly occur in 
the circulatory and digestive organs of the body. Although the 
general health may still be unimpaired, the circulation is less vigor- 
ous, and the nervous system less active to external stimulation. 
There are degenerations in the secreting organs with a tendency 
to deposition in the tissues of phosphate and carbonate of lime, 
derived from the food. Absorption is less active, and there is 
diminished adaptability of the whole system to alterations in environ- 
ment, and much less ability to meet the requirements of emergen- 
cies, such as sudden calls for the use of muscles or mental strain. 
The muscular tone of the intestine is apt to deteriorate and produce 
constipation and a relaxed condition resulting in its dilatation. The 
circulation through the mesenteric vessels and those of the portal 
system becomes inactive, with a consequent reduction in the rate 
of absorption, and a diminished and altered gland secretion in the 
liver, pancreas, etc. 

For these reasons the digestive powers are less vigorous, but, 
on the other hand, there is not so much demand for fuel in the body 
as in earlier years. The vital processes conducted by the circulation, 
respiration, and metabolic changes in the tissues are very inactive, 
and there is a correspondingly restricted expenditure of energy. 

Persons of very advanced age — those who are past eighty years 
or more — can sometimes live comfortably on an astonishingly small 
quantity of food. J. Forster examined the food of the inmates of an 
institution for elderly widows and found that many of the old women 
subsisted very comfortably upon a diet containing, in grammes, al- 
bumin, 67; fat, 38; and carbohydrates, 266. 

Much depends, however, upon the rapidity with which the 
changes above described have developed, and dietetic rules for such 
cases are not to be based upon a definite period of years so much 
as upon the degree of senility which is present in individual cases. 

Sir Henry Thompson (Diet in Relation to Age and Activity), 
in commenting upon the progressing diminution with advancing 



AGE AND FOOD 309 

years of physical energy and of the power to eliminate waste material 
from the body, and the consequent harm of overeating, says that if a 
man past his half century of life " continues to consume the same 
abundant breakfasts, substantial lunches, and heavy dinners which at 
the summit of his power he could dispose of almost with impunity, 
he will in time either certainly accumulate fat or become acquainted 
with gout or rheumatism, or show signs of unhealthy deposit of some 
kind in some part of the body — processes which must inevitably 
empoison, undermine, or shorten his remaining term of life. . . . 
The typical man of eighty or ninety years is lean and spare, and lives 
on slender rations." 

In the dietetic treatment of cases of extreme old age the rules 
which are naturally suggested are : 

1. To diminish the total quantity of food ingested. 

2. To give food at frequent intervals in small amount. 

3. To give only easily digestible food, which does not produce 
too large a residue of waste matter, either in the intestinal canal or 
in the form of excrementitious material in the blood. 

It is an undoubted fact that, having reached an advanced age, a 
man may often prolong his life and greatly add to the comfort of his 
remaining years by adhering to these rules. Yet there are many 
instances of those whose constitutional vigour is so great and whose 
appetite for the good things of the table remains so keen that they 
are unable or unwilling to listen to the dictates of reason. I recol- 
lect an instance of a gentleman who, in the enjoyment of almost 
perfect health at the advanced age of ninety-four, suddenly termi- 
nated his life by an uncontrollable indulgence in lobster salad. The 
idea is prevalent with some people that the quantity of food and 
stimulants should be increased pari passu with age, but this is as 
wrong in theory as it is pernicious in practice, and the simple fact 
that an article of particularly rich or hearty food has been enjoyed 
with impunity for many years is no argument that it can be indefi- 
nitely taken in the same degree, although this reasoning is very 
often encountered. 

In commenting upon Professor Humphrey's report upon cente- 
narians, made for the British Medical Association, Dr. Yeo observes : 
" Their habits in eating and drinking tended, as a rule, to great mod- 
eration in both. ... Of animal food the majority took but little. 
. . . The exact quantity is mentioned in nine instances : One took 
\2 ounces, one 6, one 5, and six 4 ounces daily. In the use of 
alcoholic drinks we also find evidence of great moderation." 

Some more recent investigations of the dietetic habits of men 
over one hundred years of age show considerable diversity ; thus, for 
example, some were found who ate but one meal a day, while others 
ate four or five ; some drank but little fluid, others took a great 
deal ; some were total abstainers from alcohol, and others were not. 



3IO FOODS REQUIRED FOR SPECIAL CONDITIONS 

Persons who attain to very advanced age are almost invariably 
of spare habit, and the universal testimony in regard to centenarians 
is that they have never abused food or drink, and that in the latter 
years of life, at least, they have been very abstemious in the use of 
meat. In fact, Nature usually furnishes a hint in this direction by 
depriving them of their teeth, making it practically impossible to eat 
animal food, which requires mastication, and, as Yeo suggests, " if 
artificial teeth are used for the purpose of continuing a diet com- 
posed of animal flesh, they will not prove an unqualified advantage." 

Next in importance to diminishing the quantity of food in the 
diet of the aged (especially the proportion of fats and proteid ma- 
terial) should be considered the necessity of regularity in diet, both 
in regard to the general character of the food taken and the times 
of eating. 

If the teeth are absent, tough vegetables and meats must be 
avoided, yet the food should not be wholly fluid, for some mastica- 
tion should be performed in order to maintain the salivary flow. 
Plenty of time should be allowed for this purpose. 

Any sudden changes in diet should be avoided, and the intervals 
between the ingestion of food should not exceed six or eight hours. 

It is very common for elderly people to awaken early in the morn- 
ing at three or four o'clock and to be unable to drop off to sleep 
again, but if they have some light form of nourishment at the bed- 
side, such as a glass of milk or a little gruel, which they can take 
at that time, they will often continue their sleep. 

Malt liquors are very good for the aged, and a moderate amount 
of alcohol acts as a tonic and supplies them with needed energy for 
digestion and other functions. 

Yeo gives the following suggestions in regard to the diet of the 
aged, which are so useful that they will be quoted in full : 

" Of animal foods best suited for this time of life the following 
may be mentioned. When the organs of mastication are altogether 
inefficient these foods should be minced or pounded into a paste or 
otherwise finely subdivided : 

' Young and tender chicken and game and other tender meats. 

" Potted chicken, game, and other meats, sweetbread. 

" White fish, as soles, whiting, smelts, flounders, etc. Best when 
boiled. 

" Bacon, grilled ; eggs lightly cooked or beaten up with milk. 

" Nutritious soups, such as chicken or fish, purees, beef tea, mut- 
ton and chicken broths. 

" Milk in all forms, when easily digested. 

" Beef tea and milk supply the needed mineral substances, and 
the former is an excellent stimulant. 

" The addition to milk of an equal quantity of Vichy water, warm, 
or of warm water, will often help to make it agree. 



INDIVIDUAL SIZE AND FOOD 311 

" Of vegetable foods the following are all suitable : 

" Bread and milk made with the crumb of stale bread and with- 
out any lumps. 

" Porridge and oatmeal gruel. 

" Puddings of ground rice, tapioca, arrowroot, sago, macaroni 
with milk or eggs and flavoured with some warm spices, or served 
with fruit juice or jelly; bread and butter, at least a day old; rusks 
for soaking in tea, or milk, or water. 

" Artificial foods, consisting of predigested starches. The diges- 
tive ferments are scantily provided by the digestive organs at this 
age, and soluble carbohydrates are valuable for maintaining the body 
heat. 

" All farinaceous foods should be submitted to a high tempera- 
ture for some time, so as to render the starch granules more easy 
of digestion. 

" Vegetable purees of all kinds may be taken in moderation — 
e. g., potatoes, carrots, spinach, and other succulent vegetables. 

" It is important that the use of potatoes and fresh vegetables 
should not be neglected; otherwise a scorbutic state of the body 
may be engendered. . ' ' 

" Stewed celery and stewed Spanish or Portugal onions. 

" Stewed or baked fruits and fruit jellies and the pulp of per- 
fectly ripe raw fruits in small quantity. 

" The acidity of certain stewed fruits may be advantageously 
neutralised by the addition of a little bicarbonate of soda so as to 
avoid the use of a large quantity of cane sugar to sweeten it, as this 
is apt to cause gastric fermentation and acidity. In stewing fruit, 
about as much soda as will cover a shilling should be added to each 
pound of fruit. 

" Aged persons often require their foods to be accompanied with 
some kind of condiment, which promotes their digestion arid pre- 
vents flatulence. 

" Caviare and the roes of smoked and salted herrings are of this 
nature. 

" For sweetening food, milk sugar is much less prone to excite 
acid fermentation than cane sugar. 

" A very digestible form of fat — when it is needed — is cream, 
mixed with an equal quantity of hot water and about ten drops of 
sal volatile to each fluid ounce." 



INDIVIDUAL SIZE AND FOOD 

The size of the body has more influence than its weight upon the 

quantity of food consumed. In infant feeding the relationship is 

made the subject of careful study (see Infant Feeding), but in adults 

there is more variation. As a general rule, persons of large frame 

22 



312 FOODS REQUIRED FOR SPECIAL CONDITIONS 

eat in proportion to their size, and vice versa, but there are many 
exceptions familiar to all, and some very corpulent persons are very 
abstemious at the table. Because most persons eat more than they 
really need, a man of large frame can often eat less than one of small 
size, and yet have plenty. 

Attempts have been made to demonstrate that a preponderance 
of animal or vegetable food respectively, or of some particular sys- 
tem of diet, influences the stature of men. Of course, children who 
receive insufficient food or food poor in quality may be half grown, 
but beyond that fact theories as to the specific influence of different 
classes of food upon the development of the body are founded upon 
ignorance of the natural history of the different races of man. The 
diet of Bushmen, Australians, and Fuegians presents instructive ex- 
amples of tribes with large or small bodies, demonstrating that " it 
is not quality or monotony of food, but its quantity that affects devel- 
opment " (Gerland). 

BODY WEIGHT AND FOOD 

The question as to how far gain or loss in the body weight may 
be taken as an indication of the appropriateness of diet is important. 
In prescribing systems of diet for many diseases, such as dyspepsia, 
obesity, diabetes, phthisis, etc., it is very desirable to have the pa- 
tient weighed systematically at least once a week, and good scales 
are very useful in the physician's office. Care should, of course, be 
observed that changes in clothing are not allowed to interfere with 
the accuracy of the observations. Loss of weight, under some con- 
ditions, may be much more rapid than gain ever is. The latter at 
best does not usually proceed at a rate of more than two or three 
pounds in a week, even during convalescence from such an illness 
as typhoid fever ; but in diseases like cholera, for example, in which 
emaciation is extremely rapid, the loss of weight may amount to two 
or three pounds a day, or possibly more. 

In some diseases a fallacy arises in comparing food consumption 
with body weight. In fevers there is usually loss of weight, but this 
is not always the case. Sometimes in aseptic fevers the weight may 
remain uniform ; and in phthisis there is sometimes uninterrupted 
gain during a moderate hectic. Leyden has found that in fever, 
while the albuminous ingredients of the body are diminishing, there 
may be more water stored in the tissues, and in cases of anasarca and 
dropsical accumulations of rapid development it is quite possible for 
the weight to increase, while in reality the body is rapidly wasting 
away, and it would be a very grave mistake to deduce any conclu- 
sions for feeding the patient from the weight alone. Another impor- 
tant consideration is the rapidity of loss of waste food products from| 
the body. 



SEX AND FOOD 313 

The normal weight of faeces which should be voided each day is 
five or six ounces — about one fourth of which is solid matter, the 
rest water. Many persons do not pass over half this quantity for 
days together, and thus go on accumulating waste material, which 
adds to their weight. The same disproportion between food in- 
gestion and the elimination of urea and different salts in the urine 
may exist. Moreover, the loss of weight by excessive perspiration 
may reach a pound or two a day. Athletes subjected to violent 
physical strain and stokers working in great heat — sometimes of 
120 F. — may lose two pounds in an hour in this manner. The 
night sweats of phthisis cause considerable actual loss in weight, 
besides the exhaustion which they occasion. The loss of weight 
through the aqueous vapour and carbon dioxide in the lungs may 
vary somewhat, although it is less changeable than might be sup- 
posed. 

For all these reasons it is necessary to be somewhat cautious in 
accepting conclusions from the scales for application in ordering 
more or less food, or altering its character. 

The weighing of infants immediately before and after nursing at 
the breast is an excellent and fairly accurate method of determining 
how much food they are getting, and infants whose nutrition gives 
any cause for anxiety should be frequently weighed, for in them, for 
obvious reasons, the record of slight variations in weight can be 
much more accurately utilised in regulating feeding. 

SEX AND FOOD 

The relation of sex in regard to food affects the quantity rather 
than the quality, excepting among a few rude tribes where super- 
stition is allowed full sway. The northern Eskimos, for instance, 
have a belief that if women eat eggs they cannot become pregnant, 
which is in curious contrast to the reputation for aphrodisiac effects 
which this food has among civilised people ! Women eat less food 
than men relatively because their average size is smaller, and also 
absolutely because they do less work and lead a more indoor life. 
The difference is slight, and when other conditions are equalised the 
question of sex has very little influence upon the quantity of food 
consumed. 

Generally speaking, women's digestive processes are somewhat 
less active than men's, and they have greater tendency to consti- 
pation. The accepted standards for woman as compared with man 
are as follows : The meal of a woman equals 0.8 of the meal of a 
man ; a woman with little muscular work demands 80 grammes 
protein, and a total food value of 2,400 calories ; at moderate mus- 
cular work woman requires 90 grammes protein and 2,800 calories ; 
man with little muscular work requires 112 grammes protein and 



314 FOODS REQUIRED FOR SPECIAL CONDITIONS 

3,000 calories, and at moderate muscular work 125 grammes pro- 
tein and 3,500 calories. 

About the only way in which sex affects the quality of food con- 
sumed is in the somewhat greater fondness for sweets and confec- 
tionery exhibited by females, but this can be shown to be due more 
to other considerations of habit and custom than to sex. The use 
of tobacco and alcohol by many men, for instance, . makes them 
care less for such foods. 

DIET AND HEREDITY 

The influence of heredity upon diet is not very striking. Children 
are sometimes supposed to inherit likes and dislikes for particular 
foods, whereas they are merely acquired tastes from the circum- 
stance that they have certain foods offered them at home to the 
exclusion of others. The functions of the stomach and intestines 
appear to be somewhat hereditary. Violent seasickness and a 
tendency to biliousness and constipation in some persons and the 
prompt vomiting of the contents of an overloaded stomach in others 
is sometimes a family trait, running through three or four genera- 
tions. So is occasionally the inability to digest special foods, such 
as crustaceans, strawberries, etc., but such instances are rare. 

Unfortunately, the abuse of alcohol is very strongly hereditary — 
so much so that the children of inebriate parents should be protected 
as long as possible from learning the taste of either beer, wine, or 
spirits. 

Heredity has some influence in disorders of food assimilation, 
like gout and diabetes, and in such cases improper diet and careless 
habits of eating may develop latent disease. 

DIET AND RACE 

The food of prehistoric man necessarily consisted of the simplest 
elements, represented by fruits, berries, nuts, insects, and an occa- 
sional piece of raw fish or meat. Such food is, in fact, the diet of 
primitive tribes to-day. The Fuegian lives chiefly upon shellfish 
and seaweeds, and the Central African dwarf upon plantains and 
insects (see p. 33). The name " Eskimo " was first applied by 
natives of eastern Canada in opprobrium, to signify " raw-fish 
eater." 

The history of the development of diets and of food cultivation 
and preparation is practically a history of the progress of culture, 
and most of our present foods were quite unknown to our earliest 
progenitors. The discovery of the uses of fire greatly increased 
the variety of available foods for man, for all the cereals which are 
cultivated require its use to fit them for digestion. As Gerland has 



DIET AND RACE 31 5 

said, men obtain their food from natural products, by cultivation, 
or by barter and commercial exchange, according as nomadic or 
fixed habits predominate, and " no mere hunting or fishing tribe can 
be large and remain in one place," for it is estimated that in the 
temperate zone to support one man by these means at least sixteen 
square miles of territory are necessary. 

Many a tribal, and even national war has been the more or less 
direct outcome of the necessities of obtaining food supply from dis- 
tant sources, and the economic, commercial, and social development 
of all matters pertaining to food among civilised people to-day far 
exceeds in importance all other practical questions. As man ad- 
vanced in culture and began to live in communities where division 
of labour became an important factor in development, preference 
to some extent superseded necessity in the selection of diet, and as 
food acquired a commercial value, more and more labour was be- 
stowed upon its preparation and preservation, until at the present 
time the rich are able to select their diet with almost total disregard 
of season or climate, and even the common labourer finds it eco- 
nomical to eat some foods which, like sugar or tea, may have been 
transported many thousands of miles. 

Following is a synopsis of an exceedingly interesting report 
kindly written for me by Dr. Frederick A. Cook, the physician to 
the Peary expedition to northwestern Greenland in iSgi-g2, which 
is appended to illustrate the dietetic habits of a race which, for nearly 
a thousand years, are believed to have been practically isolated from 
commercial or social relations with any of their neighbours. There 
is so little scientific information existing in regard to the dietetic 
habits of the tribe of Eskimos which he studied, who live the farthest 
north of any people in the world, that his statements will be found 
of exceptional value. One cannot peruse the account without be- 
ing impressed with the fact that generalisations in regard to the 
influences of diet upon the system should be made with great caution 
when applied to different races of man. For example, both scurvy 
and rheumatism are sometimes attributed to an excessive meat diet, 
yet the Eskimo has no starchy food at all and does not suffer from 
these diseases, and, moreover, his bodily vigour and power of en- 
durance compare favourably with that of any other race or class 
of men, and in some respects it is greater than that possessed by 
others. 

Dr. Cook says in regard to the Eskimos of northwestern Green- 
land : " They usually eat but one meal a day, which they take at 
irregular times, being people without restrictions of any kind. They 
can be seen eating and drinking whenever able to procure suste- 
nance. Their diet consists almost exclusively of meat, composed 
principally of the muscular tissues of the following animals, in the 
order of their importance to the native's: Seal, walrus, norwhale, 



316 FOODS REQUIRED FOR SPECIAL CONDITIONS • 

white whale, polar bear, reindeer, arctic hare, and sea fowls, such 
as guillemots, gulls, eider ducks, etc. When food is scarce they 
eat every part of the animal, including the stomach and intestines ; 
indeed, the only vegetable food that the most northern Eskimo can 
obtain consists of the contents of the stomach of the reindeer 
(lichens), which he is only occasionally able to secure. The women 
and children sometimes eat flowers of the arctic poppies and the 
so-called scurvy grass, but never to any great extent. In times of 
famine, in order to prevent wholesale starvation, the aged are turned 
out to starve to death, and their bodies are then devoured by the 
more vigorous members of the tribe. Occasionally, when the old 
people are shrewd and active, the younger children are sacrificed 
for this purpose. As a rule, the Eskimo will not eat dogs, but when 
food is scarce dogs are first added to their larder, and when the 
last dog has been eaten, human beings come next in order. 

" One of the greatest delicacies is old seal. A native never wastes 
the carcass of an animal ; if he should kill the seal fifty or a hundred 
miles from home he will bring it to shore and cache it in such a 
way that the foxes, bears, and birds cannot attack it. He then leaves 
it, and may not return for two or three years, when he comes back 
in anticipation of a great feast, for the old seal seems to him like 
old cheese to us, and he enjoys it immensely, although a white man 
could not endure the odour. I have known twenty individuals to 
eat a seal of this character in less than two hours, leaving only 
shreds of the skin after them. I have never been able to verify 
the statement, so commonly quoted, ' that Eskimos can eat twenty 
pounds of meat or blubber.' 

" Fully two thirds of the Eskimo food is eaten raw, and one 
half is consumed while in the frozen state. When an Eskimo woman 
starts her blubber lamp and places over it a conlipsie (the name 
applied to their primitive stew pot) she does so principally to obtain 
the warm drink which the cooked meat affords. It cannot be said 
that Eskimos cook their meat because they prefer it cooked, but 
because when the meat is heated slowly, as it can only be heated 
by their primitive method, the blood and fat ooze from the mus- 
cular tissues and form a thick soup, which, aside from water, is 
almost their only drink, and a cupful of this beverage is offered 
to every guest. The natives may consume three or four hours in 
eating one meal, and when they have thoroughly gorged themselves 
they will lie down and sleep ; as they do this, however, they place 
before themselves a dish full of cooked meat, and those who awake 
from their sleep will finish their meal, but on rising no breakfast is 
served, for the Eskimo who has a day's journey before him would 
not think of eating before starting. He claims that this would 
prevent his ability to travel, and this rule the Eskimos apply to 
their dogs as well, who are often only fed every two days. These 



DIET AND RACE 317 

Eskimos are as irregular in their habits of sleep as they are in regard 
to their meals. During the four months of constant sunshine they 
usually arise when the sun is in the south, but the Eskimo never 
thinks of going to bed until he is sleepy, so that in time of excite- 
ment, when there is a new arrival or in the pursuit of game, he will 
often remain awake for forty-eight or seventy-two hours, and then 
he will sleep ' until the spirit of sleep has left him,' as he ex- 
presses it. 

" The Eskimos endure fasting very well, and after a good, full 
meal they can fast for two or three days, apparently without serious, 
inconvenience. Indeed, when food is scarce — which usually happens 
during the period of darkness — some thrive on about one meal a 
week, but they appreciate the fact that he who is not well fed can- 
not encounter fierce storms, and no one who has not had full rations 
would think of venturing out in severe weather. During the tedious 
night of four months these Eskimos appear to undergo a state of 
hibernation, eating very little and sleeping a great deal ; their other- 
wise lively spirits are more or less subdued, and while they try to 
keep cheerful they are apt to become depressed and debilitated, and 
they are not capable of great muscular exercise during this time. 
When the sun returns their skins are somewhat jaundiced, and they 
are very anaemic. This peculiar effect was also produced in the 
members of our party in a more exaggerated form, although we 
tried many methods of overcoming the depression, and though we 
had no trace of scurvy our will powers were lessened, and our 
ambition was, to some extent, lost, and our muscular power as well 
was much reduced, so that a walk of a mile produced exhaustion. 
All of the secretions were diminished, particularly those of the 
digestive tract, and to stimulate these taxed my mental skill for the 
greater part of the winter of i89i-'92, but with us, as with the 
Eskimo, as soon as the sun returned our strength and ambition 
came back, and we felt as if we had gained a new lease of life and 
were ready to encounter any hardship. 

" The Eskimo drinks very little while eating. He usually defers 
that for some time afterwards, or perhaps until he arises next morn- 
ing, when he drinks a great deal, and while I have not measured 
the quantity of water consumed by any definite number of inches 
in twenty-four hours, I have often given Eskimo men three pints 
of water at one time, and nursing women two quarts. Before start- 
ing upon a journey a native will fill up with water. It should be 
remembered that these people use no free salt or condiments. 

" I am not prepared to say that the food of these people bears 
any relation to their stature, as other factors may influence their 
height, but their large abdominal development is undoubtedly due 
to the immense quantity of food and drink which they consume at 
one time. Variation in diet does not seem to be a necessity to the 



318 FOODS REQUIRED FOR SPECIAL CONDITIONS 

Eskimo unless he is feeling ill, when he recognises the importance 
of a change of food and surroundings. He will always hail with 
pleasure the first bird, deer, or walrus of the season. 

" The Eskimo's clothing is such a perfect non-conductor that the 
temperature does not vary much around his body, and in summer it 
is practically the same as in the coldest day of winter. For this 
reason, the extreme cold of winter does not call for a large quantity 
of food, but a native knows that his food is fuel for his body, and 
that he must take it in sufficient quantity to develop muscular power 
and animal heat. 

" The Eskimo mother nurses her child until the next is born or 
shortly before it, a period which varies in from one to eight or nine 
years, but the average time is four years. Long before the mother 
weans her child she masticates the food, opens the baby's mouth, 
and transfers the food from her own mouth to the baby's, very much 
as a pigeon does, and the child thus brought up would not think of 
taking up pieces of meat or toys or anything else to put into its 
mouth, for it will take nothing except from its mother. 

" The members of our expedition took very few forced marches 
in low temperatures. The one over the interior of Greenland was 
undertaken at the time of year when the thermometer ranges from 
5° F. below zero to 40 above. 

" The quantity of food consumed per man every twenty-four 
hours upon this expedition was as follows :: 

Pemmican i£ pound. 

Bacon, fat 6 ounces. 

Powdered pea soup 2 

Dry ship biscuits 12 ' ' : 

Condensed milk 3 " 

" A quart of tea with perhaps a pint of water was our only drink,. 
but we had no drink through the day while on the march, and often 
were unable to secure more fluid than two cups each morning and. 
night. The pemmican was composed of dried beef and beef tallow, 
half and half, a few currants, and a little sugar, but no salt. On 
several expeditions during the spring of 1892, while the thermometer 
ranged from 20 to 40 F. below zero, the members of the party 
always consumed large quantities of food. This was not, however, 
until they had been out two or three days, when the amount of 
food which they could devour seemed almost unlimited. There 
was no time that we craved for fat. We enjoyed the pemmican 
immensely, but that was because we had nothing else. During the 
extreme cold weather, while in the field, we took more kindly to 
fats, but never in preference to other foods. Canned meats, for 
some unexplained reason, were soon in disfavour,- for the variety 
and character of the food seemed to be of very little consequence ;. 



DIET AND RACE 



319 



indeed, our appetites were such that we were ready to eat anything 
and everything placed before us. We were, however, always liber- 
ally supplied with hydrocarbons, and I believe had this not been 
the case, a demand for them would soon have arisen, for the most 
valuable food for a polar expedition is composed largely of hydro- 
carbons. 

44 The most important articles of diet for a polar expedition we 
found to be pemmican, cranberry sauce, tea, coffee, chocolate, pre- 
served milk, sugar, ham, cheese, bacon, oleomargarine, lard, pickles, 
lime juice, dried fish, beef-soup tablets, wheat, corn, rye flour, rice, 
hominy, oatmeal, dried vegetables, and a liberal supply of all kinds 
of canned vegetables, particularly canned tomatoes, peas, beans, 
corn, canned soups, and dried fruits. Lime juice was not served 
regularly to the members of the expedition, and I think nothing is 
to be gained by so doing. For some of the members of the party 
it was decidedly injurious, but others called for it occasionally as 
a refreshing drink. 

" The average weight of these northern Eskimo men is one hun- 
dred and thirty-five pounds, but that of the women one hundred 
and eighty-eight pounds. Obesity is foreign to the Eskimo, and 
leanness is equally rare." 

Studies of negro diet have been made for the United States De- 
partment of Agriculture (Bulletin No. 71, 1899) by H. B. Frissell 
and Isabel Bevier, with the following result : 



Cost, Nutrients, and Fuel Value of Food per Man per Day in Dietary 
Studies in Virginia and Flsewhere 



DIETARIES OF NEGROES IN ALABAMA 

Dietary with minimum protein 

Dietary with maximum protein 

Dietary with minimum energy 

Dietary with maximum energy 

Average of 20 negro families in Alabama 

Average of 19 negro families in Virginia 

AVERAGES OF OTHER DIETARIES 
Average of 4 Mexican families in New Mexico. 

Average of 14 mechanics' families 

Average of 10 farmers' families 

Average of 14 professional men's families 

Tentative standard for man at moderate work . 



Cost. 


Protein. 


Fats. 


Carbo- 
hydrates. 


Cents. 


Grms. 


Grms. 


Grins. 


4 


26 


83 


225 


11 


99 


252 


666 


5 


3i 


27 


304 


12 


93 


283 


649 


8 


62 


132 


436 


11 


109 


159 


444 


8 


94 


71 


610 


!9 


103 


I50 


402 




97 


130 


467 


28 


104 


125 


423 




125 







Fuel 
value. 



Calories. 
1,800 
5.480 
1,625 
5-670 
3,270 

3,745 



3,55o 
3,465 
3,5i5 
3,325 

3,50o 



The preponderance of protein in the diet of Virginia negroes 
as compared with those investigated in Alabama is due to resi- 
dence nearer the sea and large consumption of fish, especially salt 
herring. 



320 FOODS REQUIRED FOR SPECIAL CONDITIONS 

Arthur Goss (Nutrition Investigations in New Mexico, U. S. 
Department of Agriculture, Bulletin No. 54) gives the following 
dietary of a Mexican living in New Mexico and an Alabama negro : 





NUTRIENTS IN GRAMMES. 


Fuel value in 
calories. 




Protein. 


Fats. 


Carbohydrates. 


Mexican 


68 
62 


73 
132 


572 
436 


3,320 


Negro 


3. 2 70 







In this dietary the Mexican subsists upon but little more than 
half of the standard requirement of protein, and the negro upon 
less than one half. The Mexican eats chiefly flour and frijoles, with 
little meat, and the negro subsists upon bacon, fish, and cornmeal. 

CLIMATE AND SEASON AND FOOD 

,Much has been written about the need of man changing his 
diet when he removes from one climate to another, in the belief that 
the natives always eat the kind of food best adapted to the climate 
in which they live. This is superficial reasoning, and too much im- 
portance is attached to the relations of climate to diet per se. As a 
matter of fact, the natives of a country eat what they can obtain 
easiest, or what their habits and mode of life have accustomed them 
to in the struggle for the survival of the fittest. " Climate affects 
diet mainly by the supply it affords " (Chambers). 

" The national dietary is determined largely by the climate and 
nature of the available soil, and among civilised communities it is 
largely modified as facilities for commerce and interchange of food 
products are increased. 

" Maritime people naturally derive much nitrogenous food from 
the sea, as fish, molluscs, crustaceans, etc. Among the residents 
of the far North albuminous and fatty diet predominates, and the 
coarser cereals — barley, rye, oats, etc. — being more hardy, predomi- 
nate in their food. Barley grows the farthest north of all the cere- 
als " (Clark). 

The Hindu subsists mainly upon rice, one of the simplest types 
of farinaceous food, and he derives his nitrogen from corn and len- 
tils. He must consequently eat a large bulk of food in order to 
obtain sufficient nitrogen for the needs of the system ; his digestive 
organs enlarge, and he finds the means of stimulating them by the 
free use of condiments of various sorts. Bulky and fibrous vege- 
table food distends the alimentary canal. The natives of very hot 
countries live mainly upon vegetable and starchy foods, eating cere- 
als, green vegetables, and pulpy fruits which contain water, salts, 
and acids in abundance, which are cooling and refreshing. As a 



CLIMATE AND SEASON AND FOOD 321 

rule, they eat less animal food than do the natives of temperate and 
arctic regions, nor do they require fats in excess, although they take 
some fats and oils. 

While these statements apply to a majority of mankind, they are 
by no means without exception, and it must not be argued that 
because a tribe eats the only food which Nature has provided, they 
could not live equally well in their own climate upon other food, 
if they could obtain it. Far from depending solely upon vege- 
table food, most savage tribes living in the torrid zone eat meat 
ravenously when they can get it, and often prefer it in an advanced 
stage of decomposition. 

The New Zealander and South Sea Islander choose a varied diet 
of fish, eggs, roots, seeds, berries, seaweeds, and meat if obtainable 
(see p. 32). 

As pointed out by Chambers, the Pampas, who eat flesh and 
drink water only, thrive on hot arid plains, and so do the Nubian 
Arabs, while the peasants of northern Norway and southern Spain 
live alike almost wholly on breadstuffs without meat. He says that 
" the immediate transition from a purely animal to a purely vege- 
table diet, though borne by the individual, is fatal to the race," and 
" the best diet in the abstract is a mixed diet, and mixed in the 
proportion selected by the experience of most civilised nations, and 
it is also best for the individual who is accustomed to it to adhere 
to under whatever sky he may be wandering." In changing resi- 
dence from one extreme of climate to another it is not advisable to 
alter the diet too suddenly, and more must depend upon the previous 
habits and occupation of the individual than upon external tem- 
perature. Meat eaters find it easier to adopt quickly another form 
of diet than vegetarians. The Dominican friars deteriorated so much 
in health in the British climate that they were obliged while resident 
in England to obtain special dispensation allowing them to eat meat 
four times a week. 

The English soldiers transported to India or Africa are not re- 
quired to become exclusive vegetarians ; and the French in Africa 
or Panama have done best upon a mixed diet. In the United States 
Surgeon General's report for 1900 the statement is made that " ex- 
perience in the Philippines has shown that though it is undoubt- 
edly true that while leading quiet lives men eat less in a tropical 
climate than in a temperate or cold climate, and particularly of 
meat or fatty substances, our soldiers during the active operations 
of last year have shown no marked tendency to lessen the quan- 
tity of fresh meat eaten. Exhausting labours and fatigues with 
corresponding wear and tear of the muscular system require a 
liberal meat issue, which the soldier uses with satisfaction and ad- 
vantage." 

" Well-clad and sheltered soldiers require less rations than poorly 



322 FOODS REQUIRED FOR SPECIAL CONDITIONS 

clad men exposed to the weather — a good thing to know in times 
of great privation " (Woodruff). 

Men often become involuntary vegetarians while travelling in 
hot climates from inability to procure meat, and may partially starve 
themselves from lack of appetite for monotonous food, variety being 
unobtainable. This leads them to resort to strong condiments, 
spices, curry, etc., to stimulate the appetite. 

Many persons, especially those past middle life and people with 
a tendency to corpulency, find that during the heat of the summer 
season, and especially during the prevalence of " heat waves," they 
are in much better health when they abstain from hot soups, fat, 
and meat, and take but little animal food of any kind. The total 
quantity of food eaten may advantageously be reduced at this time 
of the year as much as one sixth, or even one fourth. Most persons 
find this out as a matter of individual experience ; but there are 
others who should be especially directed in the matter, and the rule 
applies to infants as well as adults. The diet in winter should com- 
prise both more nitrogen and more carbon than in summer. 

The breakfast hour is often made half an hour or an hour earlier 
in summer than in winter to advantage. 

The thirst engendered by living in hot climates is conducive to 
excessive drinking, and as the water is often bad, an additional ex- 
cuse is often made for drinking too much liquor. By these means 
the foundations for hepatic and renal troubles, cirrhosis, and Bright's 
disease are often laid. On this account, in very hot climates strong 
alcoholic drinks ought especially to be avoided. In India they uni- 
formly disagree, and lighter beverages, such as beer and wines, must 
be taken very sparingly ; but there is no objection to tea, coffee, and 
chocolate. 



PART V 

FOOD DIGESTION.— CONDITIONS WHICH ESPE- 
CIALLY AFFECT DIGESTION 



HOURS FOR MEALS AND ORDER OF TAKING FOOD 

The hours for taking meals which are commonly selected are 
those which are best adapted to the varying needs of the system at 
different times in the day, and experience teaches that they must be 
varied considerably with occupation. In the larger American cities 
where commerce is active, and many men are subjected during the 
day to excitement, hurry, and strain, an evening dinner hour often 
best meets the needs of the system as well as the requirements of 
personal convenience. In the rural districts, however, and in many 
countries where life is less hurried and active than under the condi- 
tions of the extraordinarily rapid growth and development of the 
United States, it is found that taking the heaviest meal at noon 
agrees better with the wants of most persons. The hours for infant 
feeding are described under the heading Infant Feeding. 

Children should always dine early in the day. There are in gen- 
eral three systems for adults in regard to the number of meals 
and hours for taking them which are in common use, in which two, 
three, and four meals, respectively, are eaten in the twenty-four 
hours. 

The first system, which is in vogue in France and, to a less extent, 
elsewhere, is that of eating but two substantial meals a day. On 
first rising in the morning, a cup of hot coffee or chocolate is taken 
with a roll or some other simple form of bread. This enables two or 
three hours of moderate work to be accomplished before the first 
real meal, which is a breakfast eaten in the late morning, usually 
at or before twelve o'clock. This meal is substantial, consisting of 
several courses of solid food. The second meal, which is the dinner, 
is usually eaten between six and seven o'clock. This system is in 
use among workingmen as well as with the leisure classes, and is 
found well adapted to their habits of life. Americans travelling 
abroad, who are accustomed to eat a heavier meal for breakfast, often 

323 



324 FOOD DIGESTION 

find some difficulty in adapting themselves to the French custom, 
but many learn to like it, and as the travelling public are commonly 
for the time being, a leisure class, it is less difficult to adapt them- 
selves to new customs abroad than to introduce them at home. 

The Germans also usually take a cup of coffee or other light 
beverage and a roll or Butter-brod soon after rising, but they dine 
very early, often at half-past twelve, taking a heavy, deliberate meal 
at this hour, which they are apt to follow with beer and tobacco. 
Their offices and banks open early, and are often closed from noon 
until three o'clock, when they are reopened until five, whereas in 
most cities in this country the most active business hours are in 
the middle of the day, and it would be practically impossible for 
many men to give up two or three hours at this time to eating and 
social converse. The Germans usually take a supper with meat at 
a somewhat late hour — between half-past seven and eight o'clock. 
In many German towns it is customary to open the theatres as early 
as six o'clock, so that the performance is closed in time for a supper 
at nine. The habit of eating between meals and of taking occa- 
sional light lunches in the afternoon seems to be more prevalent 
there than elsewhere. 

In England it is a very common custom for the better classes 
to breakfast at eight or nine o'clock, lunch or dine between one and 
two, take a cup of tea and perhaps a biscuit at four or five, and 
dine or sup at eight o'clock. 

In the United States, where there are theoretically no class dis- 
tinctions, they practically do exist very strikingly in regard to the 
hours for taking meals, and the hard-working labouring class, 
whether employed in the city or country, almost universally dine 
at noon. It is mainly the mercantile and professional classes in large 
cities who dine between 6 and 7 p. m., while the more fashionable or 
leisure classes dine even later — sometimes at eight o'clock. Most 
of the latter, however, on going to the country for a summer holi- 
day, are accustomed to reverse their habits and dine at the usual 
country hour — at one o'clock, taking supper at half-past six or seven. 
In the Southern cities it is quite common to dine in the neighbour- 
hood of half-past two or three o'clock. Many persons in cities who 
habitually dine late on week days from long-continued custom, on 
Sundays dine shortly after noon, taking supper in the evening. This 
is an old custom handed down from days in which less exacting 
occupations favoured noon dining throughout the week, but due in 
part also to economical reasons, and a desire to make the work for 
servants as light as possible on Sunday afternoon. While those in 
good health with active digestion suffer no inconvenience from thus 
changing the hour for meals on one day in the week, there are others 
who find that it disagrees with them and disturbs their digestion. 
A hearty meal at noon following a very light breakfast, consisting 



HOURS FOR MEALS AND ORDER OF TAKING FOOD 325 

of a roll and cup of coffee or tea, may be perfectly digested for 
years, yet reversing the order of the meals may entirely disorder 
the digestion. 

For professional and other classes of men in the United States 
who are not occupied in physical labour or outdoor pursuits the 
following system is found to possess decided advantages : A break- 
fast is taken soon after rising, at half-past seven to half-past eight, 
which consists of fresh fruit, porridge or oatmeal, or other varieties 
of cereals, poached eggs or omelet, and a little bacon or fresh or 
salt fish, bread and butter, tea or coffee. The lunch, eaten between 
one and two o'clock, may consist of a lean chop, or a piece of cold 
ham, or a slice of rare beef with some stewed or baked potatoes, 
with a simple lettuce salad, or perhaps a little cheese for dessert. 
If a heavy meal is taken at this hour by persons unaccustomed to 
it, and who have had a breakfast of solid food, they often feel dull 
and sleepy for an hour or two thereafter, and are consequently 
incapacitated from active mental exercise. The dinner should be 
from half-past six to half-past seven, after the principal labours of 
the day are over, and at an hour early enough to allow of the com- 
plete digestion of the heaviest meal of the day before retiring. This 
may consist of several courses, which are conventionally arranged 
in the order which appears to be most rational and physiological — 
namely, soup, fish or an entree, a steak or joint with potatoes and 
one or two fresh vegetables, a salad, and a light pudding or cooked 
fruit. 

A clear soup at the commencement of a meal does not interfere 
with digestion, but favours it. The fluid, if taken in a quantity not 
exceeding eight or ten ounces, is, for the greater part, promptly 
absorbed in the stomach, and its warmth and the sustenance it con- 
tains act favourably upon the circulation, stimulate the secretion of 
gastric juice, and satisfy temporarily the cravings of hunger which 
are not met by the taking of solid food until after it has been 
digested for some time. The fish or entree is then eaten in the 
earlier stage of gastric secretion when the gastric juice has not yet 
attained its full strength and quantity. This is followed by the eat- 
ing of meat, which is destined to remain in the stomach for several 
hours, and requires all the energies of its digestive processes. The 
saccharine or farinaceous food, which does not undergo digestion 
in the stomach, is taken towards the end of the meal, when it remains 
a less time in the stomach than animal food. 

The discussion of more elaborate dinners, consisting, as they 
do very often, of a dozen or more separate courses, w r ould be out 
of place in this volume. Such dinners can only be indulged in for 
any length of time by those whose digestion is robust and whose 
leisure and comparative freedom from care and anxiety allow them 
to devote abundant time and physical energy to their meals and to 



326 FOOD DIGESTION 

secure sufficient holidays and trips to noted spas to enable them 
to periodically relieve the digestive system of the strain put upon 
it. Persons who rise late and dine early should eat but a small 
breakfast and a hearty supper. If the noon dinner is replaced by 
a light luncheon, a substantial breakfast should be eaten. 

Undoubtedly it is usually best to so order one's occupation that 
neither severe mental nor physical labour need be undertaken imme- 
diately after eating. Yet much depends upon the age and strength 
of the individual. 

At one of the largest colleges for girls in New England the pupils 
dine at one o'clock, and many of them commence to study imme- 
diately thereafter, or at 2 p. m. ; yet cases of indigestion are com- 
paratively infrequent among them ; and the ordinary day labourer 
begins his work again without detriment almost immediately after 
a hearty noon meal, and continues it while gastric and intestinal 
digestion are still necessarily incompleted. 

Invalids often require modification in the accustomed hours for 
meals, and Balfour says that " all invalids should have their impor- 
tant meal in the middle of the day." 

Between four and five hours, on the average, must be regarded 
as necessary for complete digestion of a mixed meal. 

The intervals between meals should be regulated with reference 
to individual peculiarities. As a general rule, convalescents or per- 
sons with feeble digestive powers and poor appetites, who are unable 
to eat a sufficient quantity of food at any one meal, should be fed 
more frequently, perhaps four or five times — that is, in addition to 
three ordinary meals, they should have light lunches in the middle 
of the forenoon and afternoon, or possibly just before retiring. The 
latter is particularly to be recommended, for if the food be light 
and nutritious, such as a bowl of gruel and a glass of hot milk, or 
a cup of cocoa with a biscuit, and possibly a glass of beer, sleep is 
not interfered with, but is promoted, and the system is saved from 
too long an interval of starvation between the hours of dinner or 
supper and breakfast. On the other hand, dyspeptics and patients 
with gastric catarrh may find it desirable to allow an interval of fully 
seven hours between their meals, in order to give abundant time for 
the digestion of one meal before that of the next is undertaken, and 
they should stop eating short of repletion. 

There are others whose digestion is good, but constitutionally 
slow, and they are better with intervals of at least six hours between 
their meals ; and there are some people who keep in better health 
on only two meals a day, and occasionally, although it must be 
regarded as an eccentricity, except in the case of some savages and 
the Eskimos (see p. 315), there are persons who thrive upon but 
one meal a day. 

The monks of La Trappe eat but one meal daily, as a religious 



APPETITE 327 

custom, at which they consume so much food that they become dull 
and lethargic for several hours afterwards (Combe). 

Many savages, like the Hottentots, have no regular times for 
eating, but, like the carnivores, take their food whenever and how- 
ever they can best obtain it. 

The business or professional man when overworked sometimes 
forms the habit of omitting his noon luncheon ; but this custom, 
although it may benefit some forms of dyspepsia, is a pernicious 
one in the majority of instances if long continued. 

APPETITE 

The term " appetite " in relation to dietetics usually means a 
pleasurable desire for food or drink, whereas hunger and thirst im- 
ply a craving for food and drink respectively, which has become 
disagreeable or positively painful. There is, however, no distinct 
line of demarcation to be drawn between these terms. 

The appetite for food is a most capricious sensation, subject to 
all manner of disturbing influences. It is to some extent appar- 
ently under control of the will, in that it can be trained to recur at 
certain intervals before taking food. In a normal state it is, there- 
fore, rhythmical, and it may then be taken as an index of the need 
of food, but when it becomes abnormal it is a very unreliable guide. 

" As a general rule, though by no means without exception, sub- 
stances pleasing to the palate are useful and not injurious to the 
organism " (Brunton). 

The appetite often appears with great suddenness, either inde- 
pendently or as the result of directing the attention to matters of 
food and eating. It may depart as suddenly, even without gratifi- 
cation, or it may vanish after the first few mouthfuls of food are 
eaten, although it was apparently vigorous a moment before. 

The appetite is aroused by a variety of circumstances and con- 
ditions, both physical and mental. Such are the smell, taste, and 
sight of food, good hygienic surroundings, exercise, bathing, cold 
or stimulating air, agreeable companionship, pleasurable mental 
emotions, and the proper preparation and serving of food. It may 
be stimulated by bitters, condiments, such salt foods as caviare or 
herring, and in some cases by alcohol. Wine drunk between meals 
is apt to spoil the appetite, but taken in moderation with meals it 
may increase it. A substance known as orexine, in the form either 
of a hydrochlorate, tannate, or simple basic condition, has been 
recommended as having the special function of exciting the appe- 
tite in convalescents. It does not, however, give uniform results, 
and I have seen little or no benefit from its use. 

To obtain the most complete satisfaction from the sense of taste 
one should swallow the food, and not merely take it into the mouth. 
23 



328 FOOD DIGESTION 

The appetite is usually somewhat more keen in winter than in 
summer, but many persons observe no difference. It is depressed 
or destroyed by mental emotion, especially grief, anxiety, and worry ; 
by the sight, smell, or taste of ill-prepared or improperly cooked 
or badly served food ; foul air and poor hygienic surroundings ; 
fatigue and exhaustion; many diseases, more particularly febrile 
diseases and most gastric disorders ; nausea ; the abuse of strong 
condiments, and of many drugs, notably opium and those which, 
like potassium iodide, produce a continual offensive taste in the 
mouth ; the abuse of alcohol ; eating irregularly and at too short 
intervals. 

In old age the appetite, especially for meats, usually becomes 
less keen, and the absence of teeth contributes to the loss of desire 
for this kind of food. There is often a dislike for cold fluids. 

A voracious appetite sometimes occurs in children and youth. 

Bulimia is the name given to this condition, which is by no means 
an indication of vigour, and is often due, according to Beale, to an 
irritable condition of the nerves of the stomach, and may be brought 
about by eating at irregular intervals, which results in disturbance 
of the gastric secretion. Such children are usually thin, and are 
encouraged by ill-advised parents or attendants to gorge themselves 
with food which they do not digest. It is a popular belief that the 
presence of intestinal worms excites a ravenous appetite. In some 
cases this may be true, especially of round worms {Ascaris lumbri- 
coides), which are very active, and which may even throw a child 
into convulsions by local irritation of the intestine. On the con- 
trary, worms of any sort may be present in considerable number 
without giving rise to symptoms. Persons whose appetites ex- 
ceed their digestive strength do well to eat very slowly. By so 
doing, the food eaten at the first part of a meal may become 
partially absorbed and lessen the desire for more before the meal 
is over. 

The appetite is very dependent upon habit and upon the usual 
order and arrangement of the meal. An attempt to eat a lump of 
butter alone usually fails, but it is easily consumed if spread upon 
bread. Reversing the customary order of the different foods served 
at a dinner usually produces disgust, and may even excite nausea. 

Abnormal Cravings 

Instances of abnormal cravings for food are familiar to every 
one. They sometimes take the form merely of an inordinate desire 
for food which is in itself wholesome but which is poorly adapted 
to an existing diseased condition. Such desire is apt to come in 
the course of any protracted illness in which a very restricted diet 
has been maintained for weeks. It is largely psychic, and does not 



VARIETY IN DIET 329 

necessarily indicate an increased appetite. The dysenteric patient 
may long for ham or pickles or vegetables, or the very obese will 
beg for sweets, preserves, or farinaceous food. 

In other cases the craving may be an indication of a positive 
want in the system, as when a scorbutic patient hungers for fresh 
fruit and vegetable acids. 

In no disease is the craving for food of every kind more pro- 
nounced than in convalescence from typhoid fever. In this case 
the hunger can hardly be considered abnormal, for it is an expres- 
sion of the need of wasted and exhausted tissue throughout the body 
for nutriment. 

Patients usually find it most difficult to give up the class of foods 
which they well know does them most harm. The subject of flatu- 
lent dyspepsia longs for saccharine, and perhaps amylaceous or fatty 
foods — confectionery, pastry, and the like — and the diabetic some- 
times has an inordinate craving for bread, which so far possesses 
him as to cause a resort to any subterfuge to obtain it. 

In disordered mental conditions, hysteria, hypochondriasis, mel- 
ancholia, and in the peculiar periods of puberty, pregnancy, and the 
menopause, cravings for wholly injurious articles may occur. Such 
patients have been known to eat chalk, or sour food, or consume 
large quantities of salt, sodium bicarbonate, etc. 

With the exception of chronic alcoholism — if alcohol be regarded 
as a food as well as a stimulant — there is no distinct food " habit," 
in the sense that any particular food is likely to be long eaten to an 
injurious excess. Those articles of diet which are oftenest abused 
are condiments and confectionery. 

VARIETY IN DIET 

Monotony of diet is not incompatible with maintenance of life, 
and even of health, when the food is restricted to two or three 
articles only, but for the reasons given in discussing the force value 
of different foods (p. 7) there is no single food, not even milk, 
which will support man in ordinary health and vigour for long. 
There are many primitive races and tribes of man who live comfort- 
ably upon a diet so restricted that it would soon prove unbearable 
for a European or an American. Much, therefore, depends upon 
custom, and no doubt upon heredity. The Hindu eats boiled rice 
and ghee, or melted butter, and the low-caste Chinese eats rice to 
the almost, but not complete, exclusion of other food ; the Eskimo 
lives upon one or two kinds of meat or fish, and a little fat; and 
the Congo native subsists chiefly upon the plantain. The Central 
American Indian lives almost entirely upon maize, and some of the 
Polynesians eat bread-fruit alone for two thirds of the year. The 
roving Indian of the North American plains originally subsisted 



330 FOOD DIGESTION 

all winter upon a diet of salt meat, and the Scotch peasants formerly 
lived for six days in the week upon oatmeal porridge. 

Such a monotony of diet is, however, usually a question of en- 
vironment and not of choice. The carnivorous Eskimo enjoys 
canned vegetables when they are offered to him, and the vegetarian 
African native gorges himself with meat when he can obtain it. As 
a rule, the more civilised the tribe of man the greater is the variety 
of his diet, and once accustomed to variety, it is very difficult to 
subsist upon a too restricted regimen. It is the ability to subsist 
upon a variety of foods which makes it possible for man to adapt 
himself so well to his environment when he migrates from one 
extreme of climate to another. 

This adaptation is also possible because the elementary foods 
possess general nutritive properties for all the organs of the body, 
rather than special value for individual structures ; for example, 
there is no " brain food " in distinction from food which nourishes 
other organs as well. 

An ideally perfect food combination if made upon purely theo- 
retical considerations of the needs of the body for just so much 
albumin, fat, starch, sugar, salts, and water would be a compound 
which in a very short time would become too monotonous and 
wearisome to be eaten. Even the domestic animals are kept in 
better condition by occasional slight changes in diet — such, for in- 
stance, as are afforded by change of pasturage or the variety which 
the season of the year produces in their natural food ; and it is well 
known that the flavour of the meat of fish and wild animals depends 
upon the nature of their diet. For example, canvasback and redhead 
ducks are much more palatable while feeding upon the wild celery 
plant than when eating other food, domestic turkeys and capons 
improve when fed upon grain, swine flesh is made better by feeding 
the animal with corn than with skimmed milk, and salmon and 
shad acquire a more delicate flavour when feeding in fresh-water 
rivers. 

In a report of digestion experiments made for the United States 
Department of Agriculture (Bulletin No. 85, 1900) by Charles D. 
Woods and L. H. Merrill, the statement is made that " it is a matter 
of common observation that digestion experiments made with one 
kind of food material do not give on the whole as reliable results 
as those in which two or more food materials are used. In other 
words, it appears that with a mixed diet the same person will digest 
a larger proportion of nutrients than with a diet composed of a 
single food material." 

Among some peoples the variety of food is considerably re- 
stricted by religious observances, custom, and associations. For 
instance, there is the Buddhist prohibition of meat and the Jewish 
prohibition of swine flesh. When a variety in food cannot be se- 



^ 



THE NERVOUS SYSTEM AND DIGESTION 33 1 

cured the desired effect in stimulating the appetite and digestive 
secretions may be obtained by altering the methods of cooking and 
by modifying the taste and odour of food. On the other hand, too 
great variety, as well as too elaborate cooking, becomes equally 
tiresome. Those who eat constantly at restaurants and large hotels, 
where the table is greatly diversified, often find that a change to 
a simpler home table agrees with them better. 

Woodruff attributes the decrease in drunkenness in the past few 
years in the United States army to the advantages accruing from 
a much greater variety in diet since fresh vegetables were made a 
part of the ration, and since by a system of exchange the soldier has 
been enabled to barter an excess of common ration food for a few 
articles of luxury. He also says : " Variety is necessary in the army 
for another reason : When the diet is very simple there is apt to 
be constipation, and in the field this condition is sometimes quite 
marked. It is recognised by physicians that chronic constipation 
cannot be properly treated with drugs, and it must be rectified by 
diet. The field ration, if possible, should overcome this tendency 
to constipation. Sluggishness of the bowels quite commonly goes 
along with discontent, homesickness among soldiers, and in such 
conditions the soldier is not a reliable fighter — he is easily beaten." 

THE NERVOUS SYSTEM AND DIGESTION 

The influence of the nervous system on digestion is very com- 
plex. In a general way, the peripheral nerves may affect the digest- 
ive process (a) through the circulation, (b) through motion, (c) 
through glandular action. The nerves chiefly concerned in these 
processes are the branches of the sympathetic system and the vagus. 
The latter, through its association with the cardiac, vasomotor, and 
respiratory centres in the medulla oblongata, places the vital func- 
tions of the body in very intimate connection with food stimu- 
lation acting through the branches of the nerve in the alimentary 
canal. 

(a) Action through the Circulation. — The nerves influence diges- 
tion through the circulation by their vasomotor control, regulating 
the calibre of the vessels and quantity of blood supplied to the walls 
of the alimentary canal, the local blood pressure, and the consequent 
rate of absorption. 

(b) Action through Motion. — The nerves influence the movements 
of the entire alimentary canal, either accelerating or inhibiting them, 
thus controlling the propulsion of the food, its admixture with secre- 
tions, and its contact with absorbing surfaces. 

(c) Action through the Glands. — The nerve supply of the digestive 
glands is distributed to their blood vessels, and also probably to 
some extent to the cells of the gland parenchyma. This latter dis- 



332 FOOD DIGESTION 

tribution is not always demonstrable histologically in man, but the 
influence is unquestionable. 

Under normal conditions, the nerves act mainly in connection 
with the digestion through reflex stimulation produced by mechan- 
ical irritation of food and by the chemical irritation of its different 
ingredients as they undergo absorption. But, in addition, nerve cur- 
rents from the central nervous system or from a remote peripheral 
origin may interfere with the normal nerve functions. Every one is 
familiar with examples of acute indigestion produced by fatigue of 
the nervous system, undue mental excitement, emotion, etc. For 
any given phase of digestion, disturbance of normal nerve function 
will retard the process more in its earlier stages by checking or alter- 
ing gland secretion. In its later stages the effect of the nervous 
system will be more pronounced in controlling or inhibiting absorp- 
tion. Overstimulation of the local nerves of the alimentary tract 
may excite an increased watery secretion and exaggerate peristaltic 
movement of the intestines, thereby hastening the passage of the 
food through them before there is time for digestion or absorption, 
and giving rise to diarrhoea. 

CIRCULATION AND DIGESTION 

The influence of the circulatory system upon digestion appears 
in the composition of the blood and in its rate of supply to the 
digestive glands. Vigorous active circulation accompanies good 
digestion and maintains a normal local reaction and temperature, 
and feeble, sluggish circulation produces local congestion of the 
viscera and interferes with gland secretion and absorption. When 
the nerves of the salivary glands are experimentally stimulated in 
animals by an electric current the blood vessels are altered in cali- 
bre. If the chorda-tympani nerve is stimulated the vessels are dilated 
and the rapidity of the blood flow is accelerated so that the venous 
blood issuing from the gland is of a red arterial hue, it not having 
lingered long enough to undergo the ordinary changes in regard 
to its gases. The salivary secretion becomes watery and contains 
a smaller percentage of solids. 

On the other hand, when the sympathetic nerves are stimulated 
exactly the reverse occurs. Hence the blood supply is shown to 
alter the digestive power of a secretion by modifying its compo- 
sition. 

Blood which is impoverished in composition, watery, anaemic, 
or deficient in albuminous ingredients, will furnish poor materials 
for the manufacture of the digestive secretions, and, further, the 
muscular walls of the alimentary canal will suffer from malnutrition 
and peristaltic action will be diminished. 



TEMPERATURE AND DIGESTION 33, 



TEMPERATURE AND DIGESTION 

Both the external temperature and the internal body heat in- 
fluence digestive processes. The effect upon the system of the 
temperature of food and drink is also a matter of important con- 
sideration. 

Hot food and drinks in cold weather, cold food and beverages 
in hot weather, are instinctively resorted to by almost every one, 
although this is, no doubt, as much due to mental association and, 
perhaps, a temporary agreeable sensation of the temperature in 
swallowing as it is to any decided influence exerted over the body 
temperature. 

Sudden modifications in the external temperature of either exces- 
sive heat or cold react upon the circulation, respiration, and the 
nervous system in a variety of ways and indirectly affect the digest- 
ive apparatus. The shock of sudden or, more particularly, of con- 
tinued exposure to cold over the entire surface of the body tends 
to constrict the peripheral blood vessels and produce congestion of 
the visceral vessels, modifying secretion and absorption in conse- 
quence. A local application of heat and of cold over the abdominal 
wall during activity of the digestive organs has but limited influence. 
Patients wearing a Leiter coil over the abdomen through which ice 
water is continually passed for many hours do not necessarily suffer 
from retarded digestion, nor do those who are having poultices con- 
tinuously applied to the abdomen. In a series of experiments which 
I have made to determine the extent of heat penetration through 
the abdominal wall it has been shown that the application of heat 
or of cold of such extremes as can be borne without discomfort has 
little or no influence on the circulation in the stomach or the in- 
testines or upon the temperature of those organs so long as the 
subcutaneous circulation is vigorous. This is owing to the rapid 
neutralisation of the heat or cold applied externally by the con- 
stantly changing layer of blood flowing beneath the surface. In 
dogs, a poultice of 140 F. or an ice coil with water at 34 F. placed 
over one side of the abdominal wall does not raise the temperature 
of a long-stemmed thermometer more than a quarter of a degree 
when slipped beneath the abdominal wall through a perforation or 
held immediately below the poultice or coil. If, however, the ani- 
mal be killed, circulation ceases, and the temperature of the ther- 
mometer will immediately be affected to the extent of fifteen or 
twenty degrees. It is doubtful, therefore, whether enfeebled diges- 
tion can be much influenced by the local application of warmth over 
the abdominal wall. Many persons, however, who have a tendency 
to intestinal indigestion find it both agreeable and salutary to wear 
continuously a broad flannel bandage about the abdomen to favour 
uniformity in temperature and prevent the liability of taking cold. 



334 FOOD DIGESTION 

It is incompatible with life that the variations of body tempera- 
ture between the highest fever and the lowest depression should 
exceed the limits of temperature at which digestion is known to 
proceed when artificially conducted, so that these alterations do not 
of themselves alone destroy digestive power in the stomach. The 
latter is usually diminished or lost during fever, but this may be 
owing more to disturbances of the circulatory and nervous systems 
than to increased warmth of the stomach. 

Efforts to raise or lower the local temperature in the stomach 
during digestion by swallowing, respectively, hot water or pounded 
ice are not productive of very striking results. 

It is customary, and no doubt best, to administer stimulants hot 
in collapse from any cause. 

Wunderlich, Fothergill, and others have laid considerable stress 
upon the antipyretic value of giving all fluids very cold in fevers, 
but I have yet to see any effect upon genuine pyrexia, as, for ex- 
ample, in typhoid fever, depending upon whether milk or other fluids 
were administered very hot or iced. I often prescribe hot boiled 
milk in such cases if patients prefer it, because the quantity of heat 
units which can be thus conveyed into the body is too small to 
merit serious consideration. 

It is a popular belief that rich wines and oils are " heating " 
foods, and, conversely, " cooling drinks " have long been used in 
fevers, but the use of iced fluids and of cracked ice itself for relief 
of thirst in fevers is of comparatively recent date. It followed the 
extended introduction of the clinical thermometer, and to this day 
one occasionally meets with opposition from mothers to giving a 
child with high fever anything really cold. 

Hot fluids drunk also favour perspiration, and sometimes aid 
expectoration, but this is because they are promptly absorbed and 
added to the volume of the blood, not because they contribute many 
heat units to the body. Winternitz endeavoured to show by sphyg- 
mograms that the imbibition of cold fluids increases arterial tension, 
and that of hot fluids lessens it. This may be true, but the sphyg- 
mograph is not at all a reliable instrument, and certainly the clinical 
application of this rule is not capable of substantiation, although in 
giving hot-air baths to promote perspiration in Bright's disease hot 
drinks are of undoubted service. 

With practice one may learn to swallow water which is uncom- 
fortably hot to the touch — at a temperature of 115 or 120 F. It 
has been swallowed at even 132 F. The drinking of very hot water 
before meals aids in cleansing the mucous membrane in cases of 
gastric catarrh and acts as a diuretic. The rate of local digestion 
in the stomach is comparatively little influenced by swallowing either 
hot fluids, such as soups or broths, or hot solid foods, and similarly 
it is not much retarded by taking such substances very cold, pro- 



TEMPERATURE AND DIGESTION 335 

vicled in each case they are swallowed very slowly. Some food is 
more digestible when eaten hot than cold, but with other food the 
reverse is true. In either case it is not so much because of the 
warming or cooling of the stomach, but because of the physical 
condition of the food. For example, some persons who cannot 
digest hot mutton fat can take it cold because it becomes friable 
and mixes better with other food. Some persons with very sensitive 
stomachs cannot take the fat of cold butter spread upon bread, but 
can digest it if melted thoroughly into hot toast, which subdivides 
the fat particles and keeps them from fusion. Hot boiled ham is 
more indigestible than cold ham for many persons. Hot milk may 
be more digestible for invalids than iced milk, yet the latter may be 
better borne if vomiting be present. Much must depend upon habit 
and individual peculiarities. One may begin a dinner with iced raw 
oysters, then take hot soup, and later conclude the meal with ice 
cream, followed by hot coffee, and yet throughout, the temperature 
of the stomach contents does not vary so much as half a degree, 
because the warm blood circulating so rapidly and abundantly within 
its walls and those of the oesophagus maintains the necessary normal 
average most favourable to digestion. Hot food is cooled and cold 
food is warmed in swallowing, and it may be said the hotter or the 
colder it is, the less likely it is to modify the rate of gastric digestion, 
for these extremes of temperature necessitate slow swallowing. 
Swallowing several tumblerfuls of iced water in quick succession 
does cool the stomach and inhibit digestion by local reduction of 
temperature, and also by shock to the gastric nerves ; but even this 
effect is less than is commonly supposed. There are about fourteen 
pounds of blood in the body, having an average temperature of very 
nearly ioo° F., all of which in turn keeps circulating through the 
digestive organs, and a single tumblerful of iced water poured into 
such a volume of warm fluid would not lower the temperature of 
the whole very much. This is why swallowing pounded ice is of 
so little avail to control gastric haemorrhage, and much less pulmo- 
nary haemorrhage, although it may relieve nausea somewhat. In 
support of these statements are the results of many experiments 
which I have made upon patients undergoing treatment by lavage, 
to whom I have given fluids at different temperatures, which were 
immediately siphoned out of the stomach, and tested for heat loss 
or gain. Two tumblerfuls of ice water may be slowly swallowed, and 
if siphoned out again in five minutes the temperature of the fluid 
will be found to have risen to fully 95 F. 

The question has often been raised as to whether the body tem- 
perature can be permanently affected by alterations in the quality 
of the diet. It may be definitely stated that so long as the diet is 
abundant and nutritious it makes no difference whether man is car- 
nivorous, a vegetarian, or lives upon mixed diet. Insufficient food 



336 FOOD DIGESTION 

and starvation or inanition from improper food, it is well known, 
reduce the body temperature to from one to three or more degrees 
below normal. Excess of alcohol also reduces it. 

Improper and indigestible food may cause temporary rise in tem- 
perature, but this is usually caused by more or less gastritis or 
gastro-enteritis, and is therefore independent of normal considera- 
tions. The total daily variation in body temperature normally pro- 
duced by the ingestion of food does not commonly exceed J° F., 
but it may reach i° F. The vegetarian rabbit has as high a tem- 
perature as a dog fed upon animal food alone. The grass-eating 
cow has a temperature two or three degrees above man's and quite 
equal to that of many strictly carnivorous animals. The graminiv- 
orous pigeon has a temperature as high as that of the fish-eating 
gull. Xo deductions can therefore be made in regard to any per- 
manent influence of diet upon normal body temperature in healthy 
animals or in man. 

The loss of body heat consequent upon starvation and inanition 
will be discussed under those headings. 



EXERCISE AND DIGESTION 

The influence of muscular exercise upon digestion is practically 
exemplified by every one's personal experience. Violent exercise, 
even by those of robust constitution, taken immediately after the 
ingestion of food almost invariably retards the process if it does 
not produce acute dyspeptic symptoms, and even vomiting. This 
is due mainly to the modification in the distribution of the blood, 
which during active exercise passes in large amount to the periphery 
of the body, and in much less quantity to the abdominal organs. 
There are also increased products of waste matter formed during 
muscular activity which circulate in the blood, and it is possible, 
though it cannot be definitely asserted, that they may temporarily 
interfere with the digestive secretions. Young children between the 
ages of four or five and ten or twelve suffer much less from the 
influence upon digestion of violent exercise than do adults. It is a 
common experience to see children romping and playing violent 
games immediately after eating without necessarily provoking in- 
digestion — a habit which would be very disastrous to adults. On 
the other hand, exercise has a vejw important relation to diges- 
tion when taken at proper times and in right amount. This influence 
is to be attributed rather to the combined effect upon the circulation 
and respiration and general functional activity of the tissues which 
promotes their nutrition than to any special local action on the 
stomach or intestines. Exercise of a certain kind compresses or 
shakes the liver in such a manner as to favour the elimination of 
bile from it and increase its functional activity. For this reason 



REST AND SLEEP AND DIGESTION 337 

horseback riding is unquestionably the most useful form of exercise 
for many varieties of dyspepsia and so-called " biliousness." Mus- 
cular fatigue following activity retards digestion very much, prob- 
ably for the reason above suggested in regard to accumulation of 
waste matter as a result of exercise. 

Moderate exercise may often be advantageously taken in the 
morning on rising for ten or fifteen minutes in order to get into a 
good perspiration before taking a cold bath. Such exercise with 
dumb-bells, Indian clubs, or weights with pulleys does not harm the 
appetite, and for some persons it is invigorating and beneficial. 
Stronger exercise, such as bicycle riding or taking long walks before 
breakfast, is not to be recommended unless the individual has been 
greatly overfed the night before. In the early morning hours, with 
an empty stomach, exposure to the influence of cold and damp, or 
possibly to infectious diseases, is believed to be greater than at other 
hours in the day. Physicians visiting cases of infectious diseases 
do well to go only at a time of day when they have recently taken 
a full meal and when they are not suffering from extreme fatigue. 

Men differ greatly in the amount of exercise which they find 
necessary to keep them in good health and maintain a normal appe- 
tite. To keep a really vigorous man in the best bodily condition 
he should take daily exercise amounting to one hundred and fifty 
foot tons of work, or an equivalent of a walk on a level of about 
nine miles ; but very few are able to accomplish this excepting day 
labourers. 

The influence of food upon muscular activity has been studied 
by Hodge, who constructed a movable cage so arranged that any 
movements of the animal which it contains are communicated to the 
cage itself, and through it to a recording tambour and kymograph- 
ion. In this manner the restless activity of the hungry animal seek- 
ing for food about its cage is recorded, as well as the indolence pro- 
duced by a satisfying fatty diet and the stimulating effect of nitroge- 
nous food. For example, he demonstrated that a mouse well fed 
on cornmeal alone may be active but a few minutes in the day. 
whereas the same animal fed upon meat and cream alone will exer- 
cise for ten hours out of the twenty-four. This is no doubt due to 
combined effects of the influence of the feeling of satiety, exhilara- 
tion, varying functional activity of different organs of digestion, and 
of the circulation and nervous system. It is to be hoped that future 
investigations will differentiate more clearlv between these factors. 



REST AND SLEEP AND DIGESTION 

The custom of spending half an hour in making a leisurely toilet 
for dinner is beneficial in giving the rest to mind and body which 
puts the latter into the most favourable conditions. Dyspeptics and 



338 FOOD DIGESTION 

persons subject to an irritable or feeble digestive system can often 
derive much benefit by observing the rule of not eating when suf- 
fering from bodily or mental fatigue. They should lie down from 
half an hour to one hour and quietly rest before each meal, which 
may then be digested in comfort. Muscular fatigue and over- 
exertion demand food for the replenishment of waste material, but 
the immediate digestive process is much facilitated by an intervening 
period of rest. It is often advisable for them to rest (but not sleep) 
for a similar time after meals. The practice of sipping hot coffee 
after dinner and of smoking a cigar is conducive to the rest which 
should be taken, whenever possible, after the ingestion of a heavy 
meal. 

Sleep is often affected by the amount of food taken. Overeating 
with lack of physical exercise combined with sedentary habits and 
brain work, is very apt to produce sleepiness. 

Sleep in Relation to Meals. — During profound sleep the different 
functions of the body are all more or less reduced in activity, and 
the motility of the stomach is lessened. The rate of circulation and 
respiration becomes slower, and gland secretion and digestive pro- 
cesses are retarded. For this reason, after eating a heavy meal at 
night, it is unwise to retire for two or three hours until the stage 
of gastric digestion is in part completed. It is true that many of 
the lower animals, particularly the carnivorous, who eat very fre- 
quently, are accustomed to lie down and sleep immediately after 
taking their food, but their functions in so many ways differ from 
those of man that but little is to be gained by a comparison with 
them, and their sleep is usually light until digestion is accomplished. 
On the other hand, in man, if profound sleep follows the eating of 
a heavy meal, digestion is very apt to be disturbed. A large volume 
of blood is kept in the abdominal vessels during digestion, and the 
cerebral circulation must be modified in consequence. It is possible 
also that the various products of nutrition which are being absorbed 
into the blood may act in stimulating the central nervous system 
in peculiar ways. Such sleep is restless, and is disturbed by dreams 
and nightmares, and even feverishness. 

On the other hand, a light doze, in cases of exhaustion and for 
the aged, taken for half an hour after dinner, does certainly no harm, 
and may promote digestion by allowing more blood to be diverted 
to the digestive organs, none being required for other activities. 

Persons whose health is below the average on account of disor- 
ders of digestion and assimilation not infrequently find that they 
become very sleepy after eating, more particularly after eating a 
heavy meal at noon ; this condition is sometimes very annoying, and 
always indicates a lack of balance between the income and output 
of energy, which must be regulated by proper attention to diet and 
exercise. Usually in such cases the difficulty consists in habitually 



REST AND SLEEP AND DIGESTION 339 

eating more food than the system can appropriate, and cleansing 
the body through the emunctories, with a temporary reduction in 
the quantity of food eaten, will remove it. In other cases the trouble 
arises from the exhaustion of the nervous system, which is unable 
to properly conduct two functions at once — that is, to regulate diges- 
tion and at the same time exercise the mind. Obviously, in such 
cases, rest and tonic treatment are indicated. The food should be 
given more often, but in small amount. 

In England the custom is very prevalent among some classes of 
people outside of the larger cities of taking four meals a day. A 
breakfast at about eight o'clock and dinner from one to two, and 
a heavy tea — that is, a lunch with tea and some solid food — between 
five and six, which is followed by supper from eight to nine. This 
practice is well adapted for some persons, especially young, growing 
children at school (see Diet in Schools), but older children are apt 
to overeat if they follow such a custom. An interval of from one 
and a half to two hours should elapse between eating supper and 
retiring, and from two to three hours between dinner and bedtime 
if the alimentary canal is too empty ; sleep will be retarded on this 
account, and the earlier stages of hunger before great exhaustion 
has occurred may be accompanied by restlessness and insomnia. A 
very little food taken into the stomach under these conditions will 
often produce sleep promptly. The aged, whose systems are sus- 
ceptible to slight changes in their condition or environment, are 
liable to become sleepy after their meals, and they find it to their 
advantage to take a brief nap after dinner ; but this sleep is not 
usually profound, and if it is too prolonged it indicates exhaustion, 
which should be met by more careful attention to the diet and stimu- 
lation. 

Hunger produces wakefulness and restlessness, and starvation 
may cause persistent insomnia. Going to bed late without dinner 
or supper results in restlessness and insomnia, which may often be 
cured by taking a glass of hot milk, or a cup of chocolate and some 
light farinaceous article, or a light sandwich and a bottle of beer. 
In all ordinary cases of insomnia it is well to see what help can 
be got from diet and regular habits before resorting to hypnotics. 
(See Insomnia.) 

In some diseases, notably diphtheria, it becomes a grave question 
between nourishment and sleep as to which is the more important. 
Vigorous local measures may be needed to control the spread of the 
membrane in the throat, necessitating half-hourly applications day 
and night, which of course interrupt sleep ; and yet the patient may 
need to be wakened for such applications, and the giving of nourish- 
ment and stimulants as well. Sleep is often more needful than food, 
and it is the duty of the physician to see that there is a proper 
balance between them. In general, in exhausting disease, protracted 



340 FOOD DIGESTION 

typhoid or other fevers, etc., nourishment must be given once in two 
hours day and night ; but if the patient does not fall asleep readily 
at night after being aroused for food, the intervals may be made 
three-hourly, and as strength returns, four-hourly. In such cases it 
is sometimes well to relax the rule, and give the patient one good 
night's rest of five hours without awakening him for food ; but the 
degree of exhaustion and need of cardiac stimulants must be the 
guide in each separate case. 



MENTAL EMOTION AND DIGESTION 

Strong mental emotion, such as fright, terror, or excessive ex- 
citement of almost any kind, inhibits the digestive functions, espe- 
cially in the stomach, but also in the intestines. Such emotion may 
be accompanied by vascular disturbances which will react upon the 
digestive organs, and in addition there seems to be a diversion of 
nerve currents from their proper course. Pleasurable emotions, 
however, affect digestion favourably, and the expression " laugh and 
grow fat " is certainly not without physiological basis. 

Hufeland wrote that " laughter is one of the greatest helps to 
digestion with which I am acquainted, and the custom prevalent 
among our forefathers of exciting it at table by jesters and buffoons 
was founded upon true medical principles." 

Prolonged anxiety and worry, in almost every instance, result in 
more or less gastric indigestion and malassimilation, so that, al- 
though the appetite may remain good, nervous dyspepsia, consti- 
pation, and loss of weight result. 



FOOD IN THE MOUTH 

The proper care of the mouth in relation to diet is an important 
subject which is frequently overlooked. In patients who are unable, 
from weakness or the prostration of fever, to use solid food or to 
cleanse the mouth themselves, lack of movement in the tongue and 
buccal muscles prevents proper cleansing of the teeth, and particles 
of food accumulate about the gums. In extreme weakness of the 
facial muscles the jaw drops and mouth breathing results. The air 
passing through the mouth evaporates the moisture present and 
gives rise to dryness of the tongue, which may become so extreme 
as to interfere with deglutition and articulation. 

In such cases the mouth should be frequently moistened by the 
nurse and swabbed out by some antiseptic, such as a saturated solu- 
tion of boric acid or diluted Listerine. This topic will be more fully 
treated under the heading Dietetic Treatment of Typhoid Fever. 

Food which is allowed to collect in the cavities of decayed teeth 
favours the development of bacteria, which on being swallowed may 



FOOD IN THE STOMACH 34 1 

become a cause of dyspepsia by exciting malfermentation in the 
stomach, especially of milk. Much bacterial filth accumulates be- 
neath artificial teeth which are not frequently cleansed. 

Imperfect or painful teeth, or swollen gums, interfere with the 
proper mastication of food, and when such conditions are present 
care should be exercised that all food eaten be soft and bland. This 
applies particularly to young children, very old persons, and the in- 
sane, who are incompetent to take care of their own mouths. 

The digestion of non-nitrogenous food begins in the mouth, and 
depends upon the activity of the salivary ferment ptyalin, which 
converts starches into dextrin and maltose. In health this action 
is prompt and vigorous, and much of the starchy food is digested 
in the mouth, in its transit along the oesophagus, and also in the 
stomach, until the gastric juice becomes so acid as to check the 
process, for ptyalin is most active upon the alkaline side of the 
neutral point, and strong acidity inhibits its power. Chittenden has 
demonstrated that after neutralising saliva, ptyalin fermentation pro- 
ceeds well in the presence of 0.005 P er cent °f hydrochloric acid, but 
stops with 0.025 per cent. Dufresne is responsible for the state- 
ment that ptyalin recovers its activity in the alkaline intestine, but 
that diastase is completely destroyed by the gastric juice. 

In feeble and ill-nourished persons the salivary digestion be- 
comes much impaired, and consequently their farinaceous food 
should be partially dextrinised artificially by diastase or by pro- 
longed cooking. 

An acid reaction in the mouth may be present because of fer- 
mentation, not because the. saliva itself is acid. In rheumatism the 
saliva is very often acid. This reaction causes a sensation of dry- 
ness, lessens the taste for food, and gives rise to thirst. Saliva which 
is rich in cells and mucus is too viscid, and does not moisten the 
food properly during mastication. When salivation is present the 
ptyalin becomes too dilute to have any digestive action upon starchy 
foods. If swallowed, the too abundant saliva carries much air into 
the stomach ; and if it is alkaline, it neutralises the gastric juice. A 
dry diet (see Dry Diet) will sometimes improve this undesirable 
condition. 

FOOD IN THE STOMACH 

Much controversy has arisen over the question as to how far the 
stomach performs the essential work of digestion, and how far the 
intestine is responsible for it. Some writers argue that the stomach 
is a comparatively useless organ except as a receptacle, and that the 
small intestine, with the different juices which are poured into it, 
is abundantly capable of doing alone the digestive work for the 
entire body. Ewald has said that the stomach is hardly to be re- 
garded as having a mucous membrane, but rather as a gland. The 



342 FOOD DIGESTION 

entire stomach has been excised from man in a number of instances, 
and although the operation has been done for relief of malignant 
disease (carcinoma), in several cases a fair measure of digestion has 
been retained and the patient has lived for more than a year. In 
these operations the oesophagus is united to the duodenum. Such 
cases prove the ability of the intestine to completely digest all 
classes of foods. 

Of recent years analysis has shown that the digestive products 
formed from the food in the stomach are by no means as complete 
in all cases as was at first supposed. The only really important 
action of this organ consists in digesting a single class of foods — 
namely, proteids — and this process is not always finished, whereas 
the intestine digests not only proteids, but fats, starches, and sugars. 
The stomach serves to warm and macerate all the food, so that it 
relieves the small intestine of much preliminary work. Gastric diges- 
tion is hindered by either acids or alkalies used in excess, by metallic 
salts, strong alcohol, and by regurgitation of bile from the intestine. 
Gillespie has found as many as twenty-four varieties of bacteria in 
the intestine, most of which are harmless. Many are introduced 
with the food and drink. 



Quantity of Gastric Juice and other Digestive Fluids 

No reliable estimates of the exact quantity of gastric juice, or, 
in fact, of any of the digestive fluids, are obtainable. At best, such 
estimates vary greatly according to different authorities. An abun- 
dant secretion is not necessarily an active one in ferment or acid, 
and the constant reabsorption of the water makes it quite impossible 
to say how much fluid has been secreted, for if the digestive juices 
be drained off and measured, the natural conditions are disturbed. 
Bile or pancreatic fluid allowed to drain off constantly through a 
fistula soon becomes altered in quality and weakened in digestive 
power. 

The estimates of the total quantity of the digestive fluids secreted 
per diem extend from three or four quarts to three gallons, and it 
is almost impossible to make exact measurements. 



Secretion of the Gastric Juice 

When food enters the stomach it immediately excites the secre- 
tion of the gastric juice. This it does at first through mechanical 
action, either upon the nerves or the cells of the gastric tubules 
themselves. The purely physical character of the food which is 
taken into the stomach will therefore, to some extent, affect the rate 
of secretion as well as the composition of the gastric juice, and 
foods are often spoken of as being either bland or irritating. The 



FOOD IN THE STOMACH 343 

former are those which are soft or in a fine state of subdivision, such 
as well-cooked farinaceous articles. The latter are the coarser forms 
of food and condiments, especially pepper, mustard, curry, pickles, 
etc., which have a more specific influence in increasing the flow of 
juice. This is probably due to reflex action through the nerves of 
the gastric mucous membrane. 

The gastric juice is secreted more abundantly in response to the 
chemical stimulus of some substances than others, as, for example, 
sodium chloride and carbonate and alcohol when taken in moderate 
dilution. If, however, they are taken to excess they cause derange- 
ment of the gastric function, and congestion ensues with secretion of 
a neutral or alkaline mucoid juice instead of the true acid secretion. 

Haidenhain has observed that the mechanical pressure of food 
against the stomach wall may be comparatively local and circum- 
scribed, whereas the chemical stimulation of the food as soon as it 
begins to be felt, causes abundant secretion from the whole surface 
of the stomach, which becomes red and turgescent from increased 
vascularity. 

The flow of juice commences almost immediately after the food 
has entered the stomach, and it continues to be secreted in varying 
quantity for two or three hours. After this period the secretion 
gradually diminishes. If the food has not been properly digested 
within a limit of three and a half hours, it may fail to pass on into 
the intestine, and while remaining in the stomach it undergoes vari- 
ous processes of malfermentation which are wholly different from 
the normal. These processes will be more fully discussed under the 
headings of the several forms of dyspepsia. By examining the in- 
terior of the human stomach when a fistula has been made, it appears 
that if the organ is empty, merely irritating the mucous membrane by 
rubbing its surface gently with a glass rod provokes the secretion 
of juice, which first appears in little clear drops at the site of irrita- 
tion. These gradually coalesce and form tiny rivulets which run 
over the mucous surface to the most dependent portion of the stom- 
ach. At the same time the mucous membrane becomes somewhat 
congested and of a pinkish hue, owing to the greater quantity of 
blood which circulates through it. 

Hydrochloric Acid 

Hydrochloric acid exists in the human gastric juice in the aver- 
age proportion of 0.2 per cent. Experimentally it is found that the 
best proteolytic digestion results with 0.1 to 0.2 per cent of hydro- 
chloric acid. The acidity is reduced upon a vegetable diet. 

The acid is secreted during active digestion but not normally at 
other times. It is often diminished in quantity, and less often it 
may be abnormally increased. Its action upon proteid foods like 
24 



344 FOOD DIGESTION 

egg albumin, blood fibrin, and meat, is to cause them to swell and 
become somewhat translucent. It contributes the necessary acid 
reaction in which the ferment pepsin causes solution of these and 
other proteids and converts them into albumoses. 

The quantity of free acid obtainable from the stomach is not 
great when much proteid food has been eaten, although its secretion 
may have been considerable. The secretion of the acid begins 
shortly after the ingestion of food, and reaches a maximum within 
about an hour. After an hour or two longer, according to the nature 
and quantity of the food present, it lessens and finally ceases. 

According to the views of some writers, the first acid formed in 
the stomach is lactic acid, which joins the alkali of chlorides in the 
blood, and liberates chlorine to form hydrochloric acid. Maly has 
advocated the theory that the hydrochloric acid was formed from 
the action of phosphates in the blood serum, splitting up the chlo- 
rides so that the highly diffusible hydrochloric acid passes readily 
out upon the free surface. 

Roberts furnishes the following table illustrating the effect of 
varying quantities of hydrochloric acid on the speed of peptic di- 
gestion : 

2 grammes beef-fibre ; i c. c. glycerin extract of pepsin ; varying proportions of 
hydrochloric acid ; water to ioo c. c. 

Proportion of dry HC1 in the Time in which digestion 

digesting mixture. was completed. 

0.05 per cent 500 minutes, almost no digestion. 

0.08 " " 200 

0.1 " " 130 •' 

0.15 " " 115 " 

0.2 " " IOO " 

0.3 •' " 115 

0.4 " " 160 " 

0.6 " " 350 minutes, embarrassed. 

The acid has an antiseptic influence, preventing the decomposi- 
tion of food, and even checking it if already begun. It is also be- 
lieved to possess an influence over the formation of pepsin. Briicke 
claims, contrary to many observers, that the acid of the stomach 
makes starch more soluble, and that much of it is also converted by 
lactic-acid fermentation in the stomach into erythrodextrin. 

Pepsin. — According to Chittenden, pepsin is a hydrolytic ferment 
which is found in the cells of the tubules of the gastric mucous 
membrane, chiefly near the cardiac portion. It exists in these cells 
in an antecedent form, or as a granular " proenzyme," which is called 
pepsinogen or propepsin, and the agent which is believed to convert 
the propepsin into true pepsin, the active ferment, is hydrochloric 
acid. This theory assigns a new function to this acid. Lactic and 
acetic acids derived from food possess the same power in lesser 



FOOD IN THE STOMACH 345 

degree. Like the other digestive ferments, pepsin belongs to the 
class of colloid or non-crystallisable, indiffusible substances. 

Pepsin digests coagulated tgg albumin even better than fibrin, 
gluten, casein, myosin, and gelatin, and hence this substance is com- 
monly employed in making quantitative tests of the relative digestive 
power of different preparations of the ferment. The standard of the 
United States Pharmacopoeia requires that pepsin shall dissolve 
three thousand times its own weight of coagulated disintegrated tgg 
albumin. The rapidity of digestion is augmented only up to a cer- 
tain point by increase in the quantity of pepsin, but beyond this limit 
it has no accelerating influence — no influence at all, in fact. 

Pepsin reaches its maximum activity at a temperature consider- 
ably higher than that of the body — namely, 130 F. Its action is 
suspended below 40 F., and destroyed between 160 and 170 F. 

The secretion of both pepsin and the rennet ferment or rennin 
which is often associated with it seems to rise and fall with that of 
hydrochloric acid, but this is not always the case. 

Rennin has been described on p. 71. 

Albumoses, Peptones. — The final product of food digestion as 
accomplished by pepsin with the hydrochloric acid of the gastric 
juice is peptone. Kuhne showed that peptone is seldom, if ever, 
pure in the stomach, but the substance produced is a mixture of 
true peptone with proteoses or albumoses, which have reactions 
that in many respects are similar. The albumoses are more highly 
diffusible than peptones. Undoubtedly both peptones and albumoses 
are formed during digestion, and both may be absorbed. 

Albumoses, like peptone, give a violet colour when added to a 
dilute Fehling solution of copper sulphate, and on boiling with 
nitric acid they exhibit a yellow colour and a precipitate which 
alternately falls on cooling and disappears upon warming. The 
albumoses may be separated from peptones by complete precipita- 
tion by saturation in aqueous solution with sulphate of ammonium. 
Bauer states it as his belief (Dietary of the Sick) " that the peptones 
do fulfil in the organism all the functions of the albuminous bodies, 
since they are again turned into coagulable albumin " ; but dissolved 
albuminates are not necessarily converted into peptones before they 
are capable of absorption (Voit and Bauer). 

Politzer, Gerlach, and others have demonstrated experimentally 
that albumoses can support nutrition and even cause gain in weight 
when given alone and free from peptones, and Hildebrandt found 
that the nitrogen of albumoses artificially fed to animals was utilised 
in the nutrition of the body to an even greater degree than the pep- 
tones of meat. 

An excess of proteids overworks the liver and produces, on 
reaching the general vascular system, various nervous disorders, 
and, it is believed by many, lithsemia and gout as well. 



S 



346 FOOD DIGESTION 

Peristalsis. — In addition to exciting secretion upon entering- the 
stomach, the food, at first by mechanical action and subsequently 
possibly through chemical stimulation, excites more or less rhyth- 
mical peristaltic movement in the muscular coat of the stomach. The 
object of this movement is fourfold: 1. To mingle the contents of 
the food thoroughly with the gastric juice. 2. To cause moderate 
trituration of the particles of food which are made to move in cur- 
rents that proceed along the greater curvature and pass back to 
the cardiac end along the lesser curvature. 3. To bring the food 
in contact successively with different portions of the mucous mem- 
brane, and to thus stimulate it and favour the absorption of such 
ingredients as this division of the alimentary canal is capable of 
taking up. 4. To favour the occasional emptying of a portion of the 
contents of the stomach into the duodenum, the movement at this 
time being accompanied by a relaxation of the pyloric orifice. 

Peristaltic action is influenced by the nature and composition of 
the food ingested, and it may be also stimulated in other ways, which 
will be more fully described in connection with intestinal peristalsis 
(see Diarrhoea and Constipation), for it may be said in general that 
those stimuli which effect intestinal peristalsis also influence this 
peculiar movement in the stomach. 



DURATION OF GASTRIC DIGESTION OF DIFFERENT 

FOODS 

Bauer says : " By the digestibility of a food one can obviously 
understand nothing more or less than the sum of the resistances 
that it offers to the action of the gastric juice." 

The time required for gastric digestion cannot be stated with 
absolute accuracy. In general, the period for the full digestion of 
a mixed meal consisting of bread, meat, and vegetables is three and 
a half hours, but because some kinds of food are thoroughly di- 
gested in the stomach, while others are acted upon but little if at 
all, the preponderance of one or other article of food in a mixed 
diet may affect somewhat the whole period of digestion. Tables 
are sometimes given in text-books of physiology in which the time 
required for digestion of various kinds of meat are stated in a very 
definite manner, but all such statements should be received with 
ample allowance for ordinary variations. If one considers for a 
moment the different elements concerned in the process of gastric 
digestion, it is obvious that the normal time required for com- 
plete digestion will vary constantly, even in the same individual in 
a state of health, for it depends upon the kind of food eaten as 
well as the following conditions: 1. Its state of subdivision, its solu- 
bility, complexity, and the process of its cooking. 2. The rapidity 
with which it is swallowed. 3. The thoroughness with which it is 



DURATION OF GASTRIC DIGESTION OF DIFFERENT FOODS 347 

masticated. 4. The activity of the stomach at the time. 5. The 
interval which has elapsed since the previous meal. 6. The condi- 
tion of the blood and nerve supply of the gastric glands. 7. The 
activity of peristaltic movement, which may either retard or hurry 
the rate of emptying the stomach. 8. The amount of fluid drunk 
with which the gastric juice is diluted. 9. The strength of the im- 
portant ingredients of this juice, its volume, and the effect upon it 
of food itself, neutralising it or not. 10. The rate of absorption. 
11. Habit. 12. Idiosyncrasy. 13. The presence of excess of fat 
or other materials incapable of digestion in the stomach. 14. The 
diversion of the nervous energy required for digestion to other 
functions, such as mental or muscular work. 

Such statements are often definitely made in articles upon die- 
tetics as that boiled mutton requires three hours for stomach diges- 
tion, while roasted mutton requires three hours and eighteen min- 
utes ; that raw oysters require two hours and fifty-five minutes and 
roasted oysters three hours and eleven minutes ; that boiled carrots 
require three hours and sixteen minutes, and the like. These figures 
may impress the lay mind as being of interest and accuracy, but when 
the above considerations have been taken into account, it must 
be seen that they are far from reliable. It is important, however, 
to state, if possible, the approximate time required for the digestion 
of certain general classes of food, and the following estimates are 
probably as nearly correct as possible in view of the above state- 
ments. 

The average time required for meats cooked by broiling, roast- 
ing, or boiling is fully three hours or three and a half hours for their 
complete digestion. Gigglberger found, as a result of feeding pa- 
tients with test meals and withdrawing the stomach contents through 
a tube, that meat requires from two and a half to five and a half hours 
for digestion, according to its quality, method of cooking, etc. 
Stewed meats need less time than roasts. Pork and very fat meat 
may require four or five or more hours for digestion, and veal needs 
at least four hours. Fresh lamb may be digested in two and a half to 
three hours. Chicken, capon, and turkey may be digested in from 
two to two and a half hours, but the meat of many of the forms of 
wild birds, such as ducks, may require four hours. Some of the vis- 
cera of animals which are eaten as food, such as brains, tripe, liver, 
and kidneys, are digested in less time — approximately two hours. 
Fish and shellfish require from two and a half to three hours for their 
digestion. Raw eggs are usually digested in less time than cooked 
ones, and they may be ready for absorption in two hours, whereas 
hard-boiled eggs require at least three and a half hours. Milk is usu- 
ally digested somewhat sooner when boiled than if raw. Milk whey 
is absorbed from the stomach, but the curds often pass on into the 
duodenum. 



343 FOOD DIGESTION 

The majority of the heavier vegetables, such as peas, beans, corn, 
beets, turnips, etc., remain in the stomach between three and three 
and a half hours, but potatoes, if baked and mealy, may remain but 
two and a half hours. Raw vegetables, such as coleslaw or raw 
cabbage and lettuce, etc., may remain two and a half hours or more 
in the stomach, and the same is true of most raw fruits, such as 
berries, apples, pears, peaches, etc. The more digestible cereals — 
rice, sago, tapioca, etc. — should pass on from the stomach within 
two hours. Fats and oils taken alone may remain in the stomach 
only a few moments. Sugars may, to some extent at least, be ab- 
sorbed from the stomach wall in the course of the first hour of 
digestion. 

Since gastric juice is fairly constant in composition, its effect in 
health upon the duration of digestion of the same kind of food 
may not vary in the same individual ; but persons differ from one 
another very much in the rapidity of their digestive processes. In 
some persons, even in health, stomach digestion may be uni- 
formly an hour or more slower than it is in others. Variations 
from the usual period of digestion are almost always upon the side 
of its retardation. The quality, composition, and quantity of the 
food all affect the rate of gastric digestion. 

Coarse food, badly cooked starchy food, excess of fats, tough- 
fibred meats, unripe fruits or vegetables, all retard digestion, and 
may prove very irritant. 

Among articles of diet, substances are sometimes eaten which 
are purely refuse material, such as the skin of potatoes and of coarse 
fruits, grape seeds, shells, soft-shell crabs, etc. 

They may pass on unaltered into the intestine and cause diar- 
rhoea, or they may sometimes linger for several days and excite 
reflex irritation. I have known undigested capsules of cod-liver oil 
to be retained in the stomach for three or four days before being 
vomited. (See Cod-liver Oil, p. 202.) 

The temperature of food and drink affecting gastric digestion is 
discussed under the heading Temperature and Digestion (p. 333). 

DIGESTION OF PROTEIDS IN THE STOMACH 

The various albuminous foods are digested best, each with a 
different degree of acidity, and it is probable that throughout a meal 
the intensity of reaction of the gastric juice varies considerably, 
becoming stronger as more food is absorbed or more juice is 
formed, or weaker as more of it passes with the chyme into the 
pylorus or as it is more diluted with additional food or drink. In 
this manner the different proteids are all certain of a fair opportunity 
for timely digestion. 

The products of albuminoid digestion in the stomach have been 



ABNORMALITIES OF GASTRIC DIGESTION 349 

carefully analysed by Kuhne and Chittenden, and are found to suc- 
ceed each other in the following order: 

1. Albuminoids or proteids. 

2. Syntonin or acid albumin. 

3. Albumoses or proteoses — proto-albumose, hetero-albumose, 
deutero-albumose. The three latter form — 

4. Peptones. 

Raw meat in the stomach turns grey-brown and swells. It takes 
longer to digest meat raw than when cooked, for the fibres are 
penetrated less easily by the gastric juice. An exception to this 
occurs when the raw meat is first scraped or made into a pulp. In 
the digestion of meats Frerichs found that the connective tissue is 
first broken down by the gastric juice, then the sarcolemma, and 
finally the substance between the striae of the muscle fibres. 

Vegetable albumin is digested in the stomach in a manner quite 
similar to the digestion of animal proteids. 

Gluten and vegetable casein are also dissolved by the gastric juice 
when strongly acid. 

Gelatin is one of the substances most easily dissolved in and 
absorbed from the stomach. It is altered by the hydrochloric acid 
of the gastric juice, so that it can no longer be solidified by cold. 
It is finally converted into diffusible substances somewhat resem- 
bling peptones, but not identical with them. 



ABNORMALITIES OF GASTRIC DIGESTION 

(The clinical examination of the stomach contents is described under that heading.) 

Hypersecretion. — Hypersecretion of gastric juice gives rise to 
thirst, sour eructations, more or less epigastric distress, and it often 
accompanies dilatation of the stomach. The secretion may digest 
proteids well, but carbohydrates are ill borne in this condition, which 
is believed to be chiefly caused by some form of neurosis. An ex- 
cess of more or less acid gastric juice passes on with the chyme into 
the small intestine, and causes an acid reaction therein, requiring 
more of the intestinal digestive fluids — bile, pancreatic juice, etc. — 
to neutralise it. The saliva is often increased at the same time, and 
Roberts suggests that this may be a provision of Nature to neu- 
tralise the acid in the stomach. 

Hyperacidity. — Hyperacidity, or increase in the hydrochloric 
acid of the gastric juice, does not necessarily imply hypersecretion 
of juice. Hypersecretion may be abundant, watery, and weak in 
acid, or more concentrated with stronger acid, or normal in quan- 
tity but with increased hydrochloric acid. 

Hyperacidity is common, and is especially apt to be present in 
connection with gastric ulcer and certain forms of chronic dyspepsia. 



350 FOOD DIGESTION 

Absence of Hydrochloric Acid. — The persistent absence of hydro- 
chloric acid from the gastric contents does not absolutely indicate 
the presence of any one disease, but rather that a considerable extent 
of the gastric mucosa is diseased, or it may be absent in nervous dys- 
pepsia without organic lesion. This condition may exist with car- 
cinoma. 

Pyrosis. — Pyrosis, or eructation of gas from the stomach, if it 
occurs very soon after ingestion of food, is usually due to lactic or 
other organic acid fermentation. Occurring later, during active 
digestion, it may be due to the same cause or to hyperacidity from 
excess of hydrochloric acid. The latter condition is less common 
when due to lactic acid ; the giving of hydrochloric acid stops further 
fermentation, whereas sodium bicarbonate, although it momentarily 
neutralises the lactic acid, soon produces an alkaline reaction in 
which the further development of the acid rapidly proceeds. On 
the other hand, pyrosis due to hydrochloric acid must be checked 
by alkalies. 

FOOD IN THE INTESTINE 

After preliminary maceration under the conditions of the mois- 
ture, warmth, and motion in the stomach, and after partial digestion 
there, the food, mixed with gastric juice, passes in a pultaceous mass, 
known as chyme, into the duodenum. Here the physical conditions 
are almost identical with those found in the stomach, but the chem- 
ical composition of the new digestive fluids — namely, the bile and 
pancreatic and intestinal juices — is alkaline, and a number of new 
ferments complete the solution and digestion of the food. 

The starches which were but partially digested by the saliva are 
converted into dextrin, maltose, and glucose by a diastatic ferment — 
amylopsin — contained in the pancreatic juice. Cane sugar is con- 
verted by the intestinal juice into glucose, any proteids which have 
been but partially digested in the stomach are completely converted 
into proteoses and peptones by the proteolytic ferment trypsin of 
the pancreatic juice, and the fats are emulsified and saponified by 
the combined action of the bile and a pancreatic ferment. 

Pancreatic juice is the most active and comprehensive digesting 
fluid of the body. It is not only much stronger than the gastric 
juice in its action upon proteids, being able to form peptones with 
fewer intermediate products, but it possesses the distinct advantage 
that it also digests fats and carbohydrates by a ferment, called steap- 
sin, which acts in either acid or alkaline media. 

Its amylolytic power is stronger than that of the saliva, for it 
digests the raw starch and cellulose which is eaten in such vegetables 
as celery, lettuce, or radishes, and in fruits like the apple. 

The ultimate products of trypsin digestion are antipeptones and 
hemipeptones. The ferment acts best in a fluid medium rendered 



FOOD IN THE INTESTINE 35 1 

alkaline by from 0.5 to 1 per cent sodium carbonate. It also digests 
proteids energetically in a neutral medium, but free acid soon de- 
stroys it. Chittenden has shown that combined acids do not neces- 
sarily put a stop to trypsin proteolysis. 

The bile plays several roles in intestinal digestion, but its chief 
action is in aiding the emulsion of fats, described below. It can 
accomplish the absorption of fats even in the absence of pancreatic 
juice. When bile is absent the fatty food may decompose in the 
intestine and develop gases and foul odours. 

Voit says that the white colour of icteroid stools is dependent 
rather upon the presence of undigested fat than the absence of bile, 
for with a meat instead of a milk diet they may still be of a dark 
colour. When a biliary fistula is made in dogs and the bile is drained 
away, they emaciate and have a ravenous appetite if fed upon meats 
and fats, but not if fed upon carbohydrates (Voit). 

The quantity of bile secreted is increased by a nitrogenous diet, 
and diminished upon an exclusive fat diet (Ufrelmann). Vegetable 
foods colour the bile green ; animal foods make it yellow or orange. 

Bile is often said to prevent putrefactive changes in the food in 
the intestine. It is not, however, an antiseptic substance, for, un- 
like the gastric juice, it easily undergoes decomposition, and the 
influence attributed to it is due rather to its promotion of peristalsis, 
thereby keeping the intestinal contents moving and preventing stag- 
nation and putrefaction. 

The Digestion of Fats. — When fat is cooked in the food, a good 
deal of it is converted into rancid fat — i. e., fat containing free fatty 
acids. In the mouth the fatty food is unaltered, unless it be in the 
form of adipose tissue, when the process of mastication breaks it 
down and liberates some of the fat globules, which are melted by 
the natural warmth. If eaten in the form of oil or butter, with 
starchy or vegetable food, the fat coats the particles of food in the 
mouth. Bread thus mingled with butter is less likely to form a large 
and too tenacious bolus. 

In the stomach the fat remains unaltered, and when the semifluid 
chyme begins to flow into the intestine it passes in with it. The 
connective-tissue elements of fatty meats, etc., are dissolved away 
and digested like other proteids by the gastric juice. 

In the intestine the fat is subjected to a double process of emul- 
sification and saponification, which is accomplished by the combined 
action of the bile and pancreatic juice. The latter splits fats into 
glycerin and fatty acid, and this action is favoured by the admix- 
ture with bile, which simultaneously occurs in the duodenum. Ac- 
cording to Rachford, the fat-splitting power of pancreatic juice is 
more than quadrupled by bile, although the latter has no fat-splitting 
influence of its own. He also declares that the presence of hydro- 
chloric acid which has just entered the upper duodenum with the 



352 



FOOD DIGESTION 



chyle, like the bile, still further aids the pancreatic action upon fats, 
as four to one. 

It is held by the majority of authorities that pancreatic juice also 
contains an emulsifying ferment, steapsm, and that the free fatty 
acid above described splits up the sodium bile salts and liberates 
their sodium, which unites with a portion of the free fatty acid, 
forming a soap. The soap coats the droplets of emulsified fat with 
a thin film (like a soap bubble) and prevents them from coalescing 
again. The emulsion is then absorbed by the lacteals. 

It is, however, not a necessary part of the theory of digestion of 
fatty food that the fat must all be emulsified. No doubt a large part 
of it is absorbed more directly or as a soap without emulsification. 

Extracts of both the liver and spleen have been said to favour 
the absorption of fats by emulsification. 

Undigested food reaches the intestines under the following con- 
ditions : (a) When too much food is eaten, (b) when gastric digestion 
is imperfect, (c) when the food is improper. 

Intestinal Gases. — During the digestion of certain foods in the 
intestine more or less gas is evolved. The gas, by distending the 
walls of the gut, serves the purpose of keeping them from agglu- 
tinating, and thereby facilitates the free movement and intermingling 
of the digestive fluids and food, and the absorption of the latter. 

Ruge has published the following table of the percentage of 
gases evolved by several different kinds of foods : 





MILK. 


MEAT. 


PEAS OR BEANS. 


Food. 


X- 


2. 


I. 


2. 


3- 


I. 


2. 


3- 


C0 2 .... 

H 

CH 4 .... 

N 2 


16.8 

43-3 
0.9 

38.3 


9.9 

54-2 

36.7 


13.6 

3-o 
37-4 

45-9 


12.4 
2. 1 

27-5 

57-8 


8.4 

O.7 

26.4 

64.4 


34-0 
2-3 

44-5 
19. 1 


38.4 

49-3 
10.6 


2I.O 
4.0 

55-9 
18.9 



ARTIFICIAL DIGESTION 

To physiologists we are indebted for the discovery and develop- 
ment of the scientific preparation of digestive ferments or enzymes 
and the predigestion of food outside of the body. The composition 
of the various digestive ferments and their action in general have 
been understood for a long time, but it is only within the last two 
or three decades that the use of these organic bodies has been made 
practicable on a large scale for rendering food more digestible or 
assimilable by invalids, and the whole question of artificial digestion 
of foods is one which is receiving more and more careful attention 
and thorough study. The subject may be said to be yet in its in- 
fancy, and it is highly probable that the extensive researches which 
are being conducted by so many investigators at the present day 



ARTIFICIAL DIGESTION 353 

will yield even more practical and important results than those al- 
ready attained. The use of predigested food at present forms an 
indispensable adjunct to the treatment of a large number of serious 
diseases, both acute and chronic, especially those which concern the 
alimentary canal, and the methods of infant and invalid feeding have 
been practically reorganised by it. 

The different ferments which can be used for increasing the ac- 
tivity of digestion within the body or for partially digested foods 
outside of the body are principally diastase, pepsin, and extracts of 
pancreatic juice, which are usually called " pancreatin," and which 
are compounds of several substances. Besides these there are sev- 
eral vegetable ferments, such as papain from the American papaw, 
and ferments are present in the juice of the pineapple, and the cen- 
tury plant or agave. 

Predigestion of Starches 

There are a variety of ferments and other materials which have 
the power of converting starch into dextrin and sugar. They are 
ptyalin in the saliva, amylopsin in the pancreatic juice, diastase, a 
ferment in the intestinal juice, and the substances inulin and lichen- 
in. The latter is obtainable from various lichens, such as Iceland 
moss. Mucin and certain gums are also amylolytic. 

Of these different ferments, the one which is found to be of most 
practical service for predigestion is diastase. 

The action of the diastase of malt resembles that of the ptyalin 
of the saliva and the amylopsin of the pancreatic juice, which alter 
starches into dextrin and maltose. It is prepared in several ways, 
as, for example, in meal of malt, which may be added to farinaceous 
foods, and in the form of malt extracts, and various malted foods 
(malted milk, etc.) are sold for invalid use or for infant feeding. 

Taka-diastase is a stable concentrated form of diastase, said to 
possess the power of converting ioo times its weight of starch into 
sugar in ten minutes. The dose is 2.\ grains after eating. 

In such preparations the predigestion of amylaceous foods is 
carried to the extent of more or less complete conversion of the 
starch into dextrin and maltose. The diastase has no action in the 
stomach provided the acid gastric juice is being secreted, for it only 
causes fermentation in a neutral or alkaline medium ; in fact, the 
ferment is probably destroyed before reaching the intestine, but it 
may act in the stomach for half an hour or so before the reaction 
of the gastric juice becomes too strongly acid. The presence of 
alkaline carbonates retards the action of diastase. In early infancy 
the amylolytic ferments of the salivary and pancreatic fluids are not 
well developed and are very meagre in quantity. If a young child 
is unable to digest milk for any reason, malted food may be tern- 



354 FOOD DIGESTION 

porarily supplied in some cases, because in it the starch is already 
more or less completely digested and is ready for absorption. In 
general, the value of malted foods and malt extracts depends upon 
the predigested starch which they contain, which furnishes nutrition, 
rather than upon the action of the diastatic ferment within the ali- 
mentary canal. 

Ground malt itself possesses even stronger digestive action upon 
starches than malt extracts. The latter contain the ferment dias- 
tase, dextrin, maltose, and a portion of the salt and some nitro- 
genous ingredients of barley. Both ground malt and malt extracts 
digest starches at a moderate heat, not exceeding 150 F. There 
are many varieties of malted foods, but Liebig's Infant Food is a 
good illustration of this type. It is prepared as follows (see also 
p. 148) : 

Mix a half ounce each of ground malt and wheat flour, seven 
and one fourth grains of potassium bicarbonate with one ounce of 
water and five ounces of sweet cow's milk. Warm slowly and stir 
until thick. Remove from fire, stirring for five minutes, replace 
over fire, and remove when quite thick. As the diastase continues 
to act the mass will become thin and sweet. Boil and strain. It 
contains gluten and albumin of flour and barley, besides dextrin and 
maltose. The food thus prepared is very nutritious, for it not only 
contains the proteid materials of the milk, but those also of the wheat 
flour and malted barley (gluten and albumin), as well as the predi- 
gested starch. The malted foods which are made with desiccated 
milk and malted flour are deficient in fats, salt, and proteid material, 
but the lack of these substances can be supplied by the addition to 
the food, when used, of cream and beef juice. The digestibility of 
bread may be increased by adding 5 grains of diastase to the pound 
of flour mixed in the dough. 

For manufacturing malted foods the wheat or barley flour should 
be baked in order to rupture the starch granules and make them 
more soluble. 

Predigestion of Proteids 

The digestion of proteids may be accomplished either within the 
body by prescribing pepsin and hydrochloric acid, or without the 
body by use of the same agents, or, as it is more often done at 
present, by pancreatinisation. 

Pepsin was the first among the digestive ferments to be isolated 
and employed for artificial fermentation. 

This ferment differs from diastase in the fact that it is capable of 
continuing its digestive functional activity within the body, and it is 
therefore frequently prescribed in cases of deficient gastric secretion, 
to be taken with the meals, or immediately after, as a powder or in 
solution. The action of pepsin is confined to the conversion of 



ARTIFICIAL DIGESTION 355 

albuminous food, and it requires an acid reaction. It is sometimes 
claimed that the continual administration of pepsin and dilute hydro- 
chloric acid may weaken the stomach by doing the work of that 
organ while it rests ; but it is difficult to see any true ground for the 
statement, for this action in no wise concerns the stomach wall or 
its secretion, but is limited to the conversion of food into more easily 
soluble material, which increases the general bodily nutrition, and 
therefore indirectly improves the stomach digestion. 

Pepsin is destroyed by dilute solutions of sodium bicarbonate as 
well as by the alkaline pancreatic intestinal fluids and the bile. It 
is obtained in a number of forms for use in aiding gastric digestion, 
such as scales, dry powder, pills, and solution. There is con- 
siderable variation in the strength of the preparations, depending 
upon the care taken in their manufacture and differences in the 
processes of extracting the ferment ; but all of them have some 
digestive action, and they are very serviceable remedies for gastric 
indigestion. 

Peptones or amphopeptones are the ultimate products of stom- 
ach digestion. They are derived from primary and secondary pro- 
teoses by pepsin proteolysis through hydration and cleavage. In 
regard to the artificial digestion of proteid foods by pepsin, Chitten- 
den says : " Peptones are truly formed, and many times in large 
amount, but never under any circumstances have I been able to 
effect a complete transformation of any proteid into true peptone 
by pepsin-proteolysis ; there is always found a certain amount of 
proteoses more or less resistant to the further action of the ferment. 
Even with a large amount of active ferment, an abundance of free 
hydrochloric acid, a proper temperature, and a long-continued 
period of digestion, even five and six days, there is never found a 
complete conversion into peptone. Indeed, the largest yield of pep- 
tone I ever obtained in an artificial digestion is sixty per cent, while 
the average of a large number of results under most favourable cir- 
cumstances is somewhat less than fifty per cent." Hence, artificial 
pepsin is not a complete digester, as often supposed, and too great 
reliance should not be placed upon it. 

Pepsin should never be given in combination with an alkali, such 
as sodium bicarbonate, excepting in cases of hypersecretion of 
hydrochloric acid with scanty pepsin formation. 

The pepsin-secreting cells predominate over the acid-forming 
cells in the stomach so largely that they are seldom destroyed to 
the same degree as the latter, and hence pepsin is of much less 
importance than hydrochloric acid in the treatment of both func- 
tional and organic disease of the stomach. It is a very common 
practice to prescribe it in tablet form without acid, but as a rule, to 
which there are almost no exceptions other than that of hyper- 
acidity, in those cases in which the exhibition of pepsin is indicated 



35^ FOOD DIGESTION 

hydrochloric acid is equally if not more important, and they should 
be prescribed together. 

The pepsin is given in doses of three to five or ten grains imme- 
diately after meals when proteid food of any kind has been eaten. 
Ten grains may be added to a pint of milk, but if long continued in 
excess of twenty grains per diem, it may excite purgation. 

Pancreatin is the name given to a complex fermentative body 
derived from extracting the pancreatic gland. It is obtained in the 
form of a dry powder, and also as a solution or liquor. Its intro- 
duction is mainly due to the researches of Dr. William Roberts, of 
England. 

The extract made from the pancreatic gland is a powerful digest- 
ive agent and, on the whole, is more serviceable for the predigestion 
of food than any of the other ferments. It contains both trypsin 
and amylopsin. This extract also emulsifies fats, and it is as easy, 
if not easier, to obtain the pancreatic extract than pepsin, and 
since its action is so powerful and varied, the majority of the pre- 
digested food preparations — the so-called " peptonised foods " — 
are made with pancreatin instead of pepsin. Pancreatin is sometimes 
prescribed by physicians for internal use, but unless protected in a 
keratin-coated capsule the ferments are entirely destroyed in the 
stomach by the action of the gastric juice. Keratin is a horny sub- 
stance derived from feathers which is not soluble in acid fluid, but 
is quite soluble in alkaline media. Hence a capsule containing five 
grains of pancreatin coated over with keratin may remain undis- 
solved in the stomach until gastric digestion is completed, when it 
will pass into the intestine, where the coating is dissolved and the 
ferments act upon the chyle. It is customary to add some alkali, 
such as sodium bicarbonate, to the pancreatin in the process of 
artificial digestion, although it will also operate on protein in the 
presence of a neutral reaction. All the products of pancreatin 
digestion, as well as the ferment derived from the juice itself, decom- 
pose if exposed for any length of time to the air. Pure meat pep- 
tones, prepared either by pepsin and hydrochloric acid or by trypsin 
in alkaline solution, are ready for immediate absorption and are 
nutritive, but a very general objection to their use exists in the 
exceedingly disagreeable odour and taste which they possess, which 
to many persons are nauseating and disgusting. This difficulty is 
overcome when peptones are used for rectal injection, for which 
purpose they are most valuable. Efforts are often made to disguise 
the disagreeable taste and odour of beef peptones in various ways. 
When obtained in solution, wines and aromatic substances are added 
to them or they are sometimes evaporated to dryness, pulverised, 
and redissolved in sherry, but the taste is exceedingly persistent and 
it is often difficult or impossible to disguise it in any manner, so that 
patients will not sooner or later object to it. Among the principal 



ARTIFICIAL DIGESTION 357 

peptones which are used are Koch's, Kemmerich's, Catillon's and 
Carnrick's, Savory and Moore's, and Benger's. Some of the pan- 
creatinised foods are strengthened by the addition of predigested 
starches and sugars. Some of them constitute very good foods 
for cases of enfeebled digestion or diminished absorptive power. 
Among them may be mentioned Benger's Food, which is made 
with cooked wheat meal and pancreatic extract. The latter par- 
tially converts the starches into malt and diastase, and when added 
to milk at the proper temperature for fermentation, it acts upon the 
casein and converts it into a soluble peptone. Oat flour and lentil 
flour are similarly prepared. Carnrick's Infant Food is made on the 
same principle with Benger's Food, with wheat flour, pancreatin, 
and milk, to which is added a certain percentage of lactose. Savory 
and Moore prepare a concentrated predigested milk and milk with 
cocoa, which have an agreeable taste and considerable nutrient 
value. Another preparation is Loeflund's Peptonised Kindermilch. 

All peptonised or pancreatinised foods are open to the objection 
that they are much more expensive if used for a long time than the 
preparations which can be easily made at the bedside by any intel- 
ligent person by the use of the simple pancreatin extracts. Among 
these extracts are Benger's Liquor Pancreaticus and Peptonising 
Powders and Fairchild's Zymine, which act upon lean meat as well 
as milk. If complete peptonisation is required, large quantities of 
the ferment must be used, and the process should be continued 
longer than for a lesser degree of peptonisation. One. or two 
drachms of Benger's Liquor Pancreaticus with fifteen grains of 
sodium bicarbonate will completely peptonise half a pint of milk in 
a few minutes if the bottle be immersed in water which is heated, 
but which is not too hot for the hand to bear. Roberts's rule for 
pancreatinised milk gruel is quoted by Yeo as follows : " A good 
thick gruel made with oatmeal or other meal while still boiling hot 
is added to an equal quantity of cold milk. The temperature of the 
mixture will then be about 140 F. To a pint of this mixture two 
or three teaspoonfuls of Liquor Pancreaticus and twenty grains of 
bicarbonate of soda are added ; it is kept at the same temperature 
for about two or three hours, and then boiled for a few minutes and 
strained. This mixture contains not only the casein of the milk 
peptonised, but the starch of the material is converted into sugar 
and its albuminates are peptonised. The bitterness of the pepton- 
ised milk is scarcely perceptible in this gruel." 

Papoid is a vegetable ferment derived from the papaw tree 
(Carica Papaya) which is thus described by Chittenden : 

■" Extended study of the reactions of the vegetable ferment pa- 
poid shows that it is composed essentially of a mixture of vegetable 
globulin, albumoses and peptone, with which is associated the fer- 
ments characteristic of the preparation. 



358 FOOD DIGESTION 

" Papoid, so far as my observations extend, has the power of 
digesting to a greater or less extent all forms of proteid or albu- 
minous matter, both coagulated and uncoagulated. Furthermore, 
papoid is peculiar in that its digestive power is exercised in a neu- 
tral, acid, and alkaline medium. 

" Papoid will act in dilute solutions, but the best and character- 
istic action is seen only when a small volume of fluid is present. 
In this respect it differs very markedly from the animal ferment 
pepsin, and for this reason any direct comparison of the two fer- 
ments is practically impossible, but blank experiments without pa- 
poid [with acid and alkali as used in these experiments] showed 
that these reagents have in themselves only a comparatively light 
solvent action on raw fibrin." After ingesting the ferment it is found 
in the stools, showing that it is not wholly destroyed in the alimen- 
tary canal. The dose is from one to three grains after each meal. 

Caroid is a vegetable digestive ferment made, like papoid, from 
the papaw (Carica Papaya) in the form of a dry yellowish powder. 
According to Chittenden's analysis, it retains a strong proteolytic 
action in either acid, neutral, or alkaline media. It softens and dis- 
integrates proteids, coagulates milk like rennet, and is also anxio- 
lytic. It is a solvent of gastric mucus. 



FOOD ABSORPTION 

The absorption of food takes place from the stomach to a limited 
extent, to a great degree from the small intestine, and to a lesser 
degree from the larger intestine. The rectum is capable of absorb- 
ing enough predigested food to sustain life for several weeks. (See 
Food Enemata.) The entire digestive process does not have to be 
completed before absorption begins. Usually those foods which 
are first digested, or which are administered in predigested form, 
are first absorbed. 

The rate of absorption depends upon the degree of digestibility 
of the food, the extent of absorbing surface with which it is brought 
into contact by the peristaltic movement, the composition of the 
blood, the relative pressure in the intestine, blood vessels, and 
lymphatics, and, probably more than anything else, upon the func- 
tional activity of the cells covering the intestinal villi. The accom- 
panying table shows the percentage of food swallowed which is 
actually absorbed : 



Weight of Food. 


Absorbed. 


Residue. 




89.9 
8l.2 
96.9 


II . I 




18.8 


•• ** fats or carbohydrates 


3-1 





ELIMINATION OF FOOD WASTE 



359 



ELIMINATION OF FOOD WASTE 

The data given below, which are derived from Bauer, exhibit the 
balance of income of food and output of waste of the body under 
different conditions of rest and activity. 

Income of Food and Output of Waste (Bauer) 



Income 

Meat 

White of egg 

Bread 

Milk 

Beer 

Suet 

Butter 

Starch 

Sugar 

Salt 

Water 

Oxygen from air 

Total 

Output 

Urine 

Faeces 

Breath 

Total 

Balance 



Rest and 

abundant diet. 


Work and 
abundant diet. 


Small, ill-nour- 
ished man ; 
rest and _ 
abundant diet. 


Grammes. 


Grammes. 


Grammes. 


139-7 
41-5 


I5I-3 
48.I 


I5I-I 
61.8 


450.0 


450.O 


450.0 


500.0 


500.0 


509.6 


1,025.0 
70.0 


1,065.9 
6o.2 


I,OI2.7 
58.8 


30.0 


30.0 


30.0 


70.0 


70.0 


70.0 


17.0 


I7.O 


17.0 


4.2 
286.3 
709.0 


4.9 

489.I 

1,006. I 


4-3 
4I.4 

600.7 


3.342.7 


3,892.6 


3,007.4 


i,343-i 


I,26l. I 


1,069.6 


"4-5 


I29.O 


I37-I 


1,739-7 


2,545-5 


i,597.8 


3,197.3 


3,935-6 


2,804.5 


+ 145-4 


-43-o 


+ 202.9 



The following data are quoted by Yeo : 

" According to Dujardin-Beaumetz, a man loses, in connection 
with the processes of nutrition, nitrogen, carbon, water, and salts, 
In twenty-four hours these losses [for an adult man at moderate 
labour], on an average, amount to 20 grammes (300 grains) of nitro- 
gen, 310 grammes (4,650 grains) of carbon, 30 grammes (450 grains) 
of salts, and 3 litres (about 6 pints) of water. The chief part of the 
nitrogen (14.5 grammes) passes away in the urine in the form of 
urea and uric acid, and the remainder (5.5 grammes) in the faeces, 
perspiration, and mucous discharges. Of the carbon, 350 grammes 
are consumed in the lungs, 45 grammes are eliminated by the kid- 
neys, and 15 grammes in the other secretions. The water passes off 
by the skin, lungs, kidneys, and bowels. A man's food must con- 
tain the elements necessary to repair these incessant losses. 

" The 20 grammes of nitrogen represent 124 grammes of dry 
proteid matters, and as these contain 64 grammes of carbon, on 
subtracting the 64 grammes from the 300 grammes necessary for 
25 



360 FOOD DIGESTION 

nutrition there remain 236 of carbon to be derived from starch 
substances or from fats." 

When waste matter has accumulated in the system its elimina- 
tion may be assisted in various ways, as follows : 

1. Through active exercise, which produces more complete oxi- 
dation and the formation of a larger proportion of water and carbon 
dioxide. 

2. By diuretics, large draughts of saline waters, and occasional 
doses of saline cathartics. 

3. By Turkish baths, which increase the elimination from the 
skin. 

THE URINE AND FOOD 

The relation of the composition of the urine to the quality and 
quantity of the food is highly important. 

Independently of renal disease and of excessive perspiration, the 
occurrence of a scanty urine means that too little fluid is being 
ingested, and that the nitrogenous waste is accumulating faster than 
it is being removed. 

The urine secretion is normally increased in quantity after meals, 
and is diminished during fasting and in sleep. The increased rate 
of secretion lasts for two or three hours, and then lessens. The 
increase usually begins within an hour after breakfast, but not for 
two or three hours after dinner. This may be owing to the slower 
absorption of fluid which occurs with the heavier meal — i. e., while 
solid food is retained in the alimentary canal, it holds back the fluid 
like a sponge. The maximum rate of secretion is also reached 
somewhat later after dinner, sometimes not for four hours. 

After mixed meals the quantity of urea is more than doubled, 
and the phosphates and urates are increased in nearly the same ratio. 
Proteid foods always increase the output of urea, urates, or uric 
acid, while vegetable foods increase the phosphates and sulphates. 

Klemperer has stated that in diseases characterised by nitro- 
genous tissue waste the latter is reduced by giving carbohydrates. 
In other words, the carbohydrates save the consumption of tissue 
and consequent production of urates or urea. 

Meat and albuminous foods in general tend to make the urine 
more acid, whereas milk and vegetables make it more alkaline. 

TOBACCO AND FOOD 

The use of tobacco in its relation to digestion is a subject very 
closely allied to dietetics, but a brief mention of it only can be made 
here. Like alcohol, undoubtedly most persons are better without 
it, and its abuse is well known to disorder digestion through the 
action of nicotine upon the circulation, and especially upon the 
vagus nerve. No definite rules can be formulated for the use of 



FOOD EQUIVALENTS 



361 



tobacco in relation to meals beyond those suggested by the fact 
that the action of tobacco is always less likely to prove irritating 
if it is smoked while there is abundant food in the stomach. The 
after-dinner cigar in many persons promotes the secretion of gastric 
juice, and there are those in whom a mild cigar after breakfast 
favours peristalsis and the evacuation of the bowels. If there is 
any tendency to indigestion of starchy or saccharine foods, it is 
usually aggravated by the use of tobacco in any form. 

As observed elsewhere, when food cannot be obtained after 
fatiguing exercise or a forced march, the moderate use of tobacco 
is often found to temporarily replace it, at least to the extent of 
lessening the feeling of weariness. (See Substitutes for Food, p. 
282.) Smoking immediately before meals may destroy the appetite 
and interfere with the digestion of the food. 



FOOD EQUIVALENTS 

It is easy to compute the chemical equivalents of foods as ana- 
lysed outside of the body. It is quite another matter to compute 
them with accuracy within the body. Most writers upon dietetics, 
however, make some attempt to do this, and the following data may 
be accepted as approximately correct : One pound of lean beef equals 
in nutrient value three eggs or two pints of milk. Roast beef con- 
tains about the same protein percentage as an tgg, but much more 
fat. One pound of wheat equals 3.5 pounds of potatoes. 

Of common cheese, Parkes estimated that " about half a pound 
contains as much nitrogenous substance as one pound of meat, and 
one third of a pound as much fat." It requires about 27 pounds of 
milk to make a pound of butter, and about 10 pounds to make a 
pound of cheese. 

Van Noorden estimates that as a fat former seven grammes of 
fat equal 9.3 grammes of alcohol. 

Oertel says that " one part of fat is iso-dynamic with 2.4 parts of 
carbohydrates, on an average," and one part of fat develops as much 
heat and force as 2. 11 parts of albumin (Voit). 

Church gives the following table of the estimated equivalents of 
foods which would yield the necessary daily supply of nitrogen if 
eaten alone : 





Pounds. 


Ounces. 




2 
2 

3 

24 

54 
6 

3 


IO 








I 




13 




White turnips 


4 




8 




7 





362 FOOD DIGESTION 

To obtain the necessary daily supply of carbon 





Pounds. 


Ounces. 




Bacon 


8 
2 

5 
1 
20 
6 
6 


II 

8 

3 
11 


6 




Cow's milk 




Wheat bread 




Ee'e's 




Rice 




Turnips 




Lean beef 




Potatoes 









PART VI 

THE GENERAL RELATIONS OF FOOD TO SPECIAL 
DISEASES.— DISEASES WHICH ARE CAUSED BY 
DIETETIC ERRORS 



THE GENERAL RELATIONS OF FOOD TO SPECIAL 

DISEASES 

There are two methods of adapting diet for the sick : First, by 
giving one half, one third, or one fourth of the ordinary quantity 
of food for health ; second, by altering the quality of the different 
classes of foods, and reducing the total amount simultaneously or 
not, as required. The former method is simpler and less trouble- 
some, and for some few cases it may prove sufficient. It is to be 
regretted that it is a routine method adopted in many hospitals, for 
it is unscientific, besides being often wasteful and radically wrong. 
The second method presupposes a knowledge of the relations of 
diet to disease, and requires careful supervision. In speaking of 
this subject Parkes wrote : " It is certain that the physician can in 
this way wield a great power, which, if less striking than that ob- 
tained more rapidly by drugs, is yet of immense moment." 

The same aliments which in health produce definite results in 
furnishing energy and repairing tissue loss may fail completely in 
disease. Such is the case in diabetes when starches become not only 
a useless but a harmful food, and in severe albuminuria, when meats 
only aggravate the albuminuric waste. 

In the majority of severe diseases, and especially of acute and 
febrile diseases, the proteids and fats, aside from those of milk, be- 
come less assimilable than the carbohydrates. Beneke attributes 
this to the fact that carbohydrates are respiratory foods — i. e., their 
consumption results in the production of carbon-dioxide gas and 
water, and the elimination of carbon dioxide proceeds in disease 
very much as in health. If carbohydrates are not therefore fur- 
nished, inanition ensues, for the tissues begin to consume their own 
substance. 

There are, on the other hand, some few diseases, such as tuber- 

363 



364 GENERAL RELATIONS OF FOOD TO SPECIAL DISEASES 

culosis, chlorosis, and secondary anaemia, in which proteids and fats 
may be distinctly required, and others again may temporarily de- 
mand a purely nitrogenous diet. 

Food improper in quality or deficient in quantity is sure to be 
not only a direct source of disease, but indirectly, by lowering the 
vitality of the body, it leaves it an easy prey to epidemic and con- 
tagious diseases of every sort. This was strikingly shown during 
the ravages of the plague in the Middle Ages, and it has been ap- 
parent in the history of all recent famines. (See Starvation, p. 297, 
and Famine, p. 304.) 

The important relation of food to disease in regard to its quantity 
and composition, as well as the frequency and method of its ad- 
ministration, are becoming more and more thoroughly appreciated. 
This is owing in great part to improved methods of diagnosis and 
to modern means of clinically discriminating between different kinds 
of gastric and intestinal indigestion. It is also due to an increasing 
knowledge of the chemistry of food, of food preparation by cooking, 
and of " artificial digestion." 

There is still much difference of opinion in regard to the best 
dietaries for certain diseases, such, for example, as gout and obesity, 
but the general principles of dietetics are to-day well established and 
more widely understood and practised than ever before, and starva- 
tion in fevers, like excessive venesection and similar depleting meas- 
ures, is no longer carried to the former injurious extreme. There 
remains much to be learned in regard to dietetics ; and the great 
variations in digestive power which are encountered in individual 
cases of disease and in personal idiosyncrasy, together with the 
increasing varieties of foods and food preparations, make the rela- 
tion of diet to disease a constantly broadening subject, the impor- 
tance of which cannot be overrated. It is to be regretted that the 
study of dietetics is not more thoroughly taught as a necessary 
part of medical education, and that thorough systematic instruction 
in this practical branch of science is omitted from the curriculum 
of most medical schools. For many physicians it seems far easier 
to write a brief prescription for a " nerve tonic " or cathartic pill 
than to take the time and pains to state in writing for their patients 
a definite dietary which in very many cases will prove an invaluable 
adjunct to medicinal treatment, if not in itself a curative measure. 
Sometimes indeed they appear possessed with the idea that the 
minutiae of dietetics are beneath consideration, whereas in reality, 
like the details of good nursing, they are most important, and a 
careful attention to them and a close interrogation into the ordinary 
habits of the patient in regard to his daily regimen is sure of appre- 
ciation and of beneficial results. 

In all acute febrile diseases and in all so-called " wasting " dis- 
eases in which there is faulty assimilation of the food, the digestive 



DISEASES CAUSED BY DIETETIC ERRORS 365 

functions are impaired, while the rapid tissue waste increases the 
need for nutriment to replace it. In such cases enfeebled digestive 
powers must be taken into account, and while endeavouring to sup- 
ply the increased demand for food, every effort should be made to 
relieve the alimentary canal of unnecessary labour by supplying 
those preparations which will yield the necessary amount of nutri- 
tion and force with a minimum expenditure of energy. More- 
over, the conditions of elimination of waste materials from the 
tissues must be studied in relation to the composition of dif- 
ferent foods in order to prevent the overworking of the excretory 
organs. 

It may be asserted that there is almost no disease of long dura- 
tion and severity, and certainly no disease accompanied by grave 
constitutional disturbances, the course of which cannot in a measure 
be controlled or benefited by thorough study of the nature and uses 
of foods. There are many acute aliments in which undoubted bene- 
fit is derived from greatly diminishing or altogether withholding 
temporarily the consumption of food, while there are others in which 
forced feeding — that is, increasing the quantity of food to the utmost 
capacity of the digestive organs — is a necessity. 

The general relations of food to the organism, as well as the 
nature of foods and the processes involved in their digestion, ab- 
sorption, and assimilation, have received full consideration in the 
preceding pages. In the following chapters the principles briefly 
outlined above will be considered in their application to individual 
diseases. At the risk of some repetition, it has been thought best 
to make the dietetic treatment of each disease as comprehensive as 
possible under the different headings considered, and to emphasize 
its value by a brief synopsis of the more important symptoms which 
arise, and a discussion of the indications to be met by appropriate 
dieting. 



DISEASES CAUSED BY DIETETIC ERRORS 

While the course of the majority of all diseases is obviously 
influenced by the quantity and quality of the food eaten, there are 
particular diseases which are directly caused by improper diet. This 
causative relation concerns : 

I. Insufficient food. II. Overeating and overdrinking. III. 
Food in itself wholesome, but which is injurious because the in- 
gredients are not properly balanced. IV. Food containing parasites 
or their embryos. V. Food containing ptomaines. VI. Food con- 
taining other poisons, grain poisoning, etc. VII. Food containing 
adulterants. VIII. Food containing micro-organisms. IX. Food 
which is in itself wholesome, but against which personal idiosyncrasy 
exists. X. Alcohol as a food and poison. 



366 DISEASES CAUSED BY DIETETIC ERRORS 

I. Insufficient Food 

The general effects of starvation have been described in the study 
of the proper quantity of food (p. 297). The effects of the depri- 
vation of water are discussed on p. 43. Insufficient food may 
cause the condition of marasmus, and is an important agent in pro- 
ducing some forms of anaemia. (See Marasmus.) 

II. Overeating and Overdrinking 

Both overeating and overdrinking may be (1) temporary — that 
is, the result of an occasional debauch ; or (2) chronic. 

1. Temporary overeating may apply to the excessive consump- 
tion (a) of a mixed diet, or (6) of particular articles of food. The 
former (a) causes dyspepsia, or, in extreme cases, acute gastroenter- 
itis. The latter (b) may also cause dyspepsia and diarrhoea, or such 
affections may be produced as glycosuria, from excessive indulgence 
in candy and sweets ; acne and other skin diseases, from the too 
liberal consumption of fats. 

Temporary overeating at one or two meals may not produce any 
serious effect, but if the excess in feeding be long continued a variety 
of ills result, attributable directly to overloading of the alimentary 
canal and to the accumulation of waste matter in the tissues, and 
consequent imperfect oxidation processes. 

The excess of food may be injurious in one of two ways : 

First, if it is not absorbed, it ferments abnormally in the alimen- 
tary canal. There is a limit to the quantity of every food which 
can be digested in a given time ; beyond this the food, whether 
starches, fats, sugars, or proteids, may decompose, or pass away 
unaltered. 

Second, if the excess be absorbed the blood is overwhelmed, and 
the excretory organs are overworked. 

The inability to sing with precision after a too hearty meal is 
often attributed to temporary congestion of the vocal cords. While 
this is observed in the thickened speech of alcoholism, the difficulty 
in singing caused by overeating is mainly due to inability to regulate 
the actions of the diaphragm and other respiratory muscles when 
the stomach is too greatly distended. 

2. Chronic overeating may cause such diseases or diatheses as 
obesity, gout, lithaemia, oxaluria, and the formation of renal, vesical, 
and hepatic calculi. It is very certain to cause congestion of the 
liver and the condition known as " biliousness," in which the stom- 
ach and intestines are engorged, constipation results, the tongue is 
heavily coated, the bodily secretions are altered in composition, the 
urine especially becoming overloaded with salts, the liver becomes 
congested, and finally the nervous and muscular systems are affected, 



OVEREATING AND OVERDRINKING 367 

with the result of the production of headache and feelings of fatigue, 
lassitude, drowsiness, and mental stupor. 

For persons leading sedentary lives, excessive consumption of 
animal food is more injurious than that of vegetable food, for the 
reasons given above, although obesity is more favoured by excess 
in vegetable diet and sweets. The nitrogenous foods, requiring, as 
they do, a large consumption of oxygen for their complete com- 
bustion and reduction to urea and allied products, produce forms 
of waste matter in the system which are more deleterious than the 
carbohydrates that are converted into water and carbonic acid, and 
are more easily eliminated. It is for this reason that defective nitro- 
genous metabolism alters the composition of the blood and paves 
the way for disorders of nutrition, such as lithiasis. 

Patients suffering from severe epilepsy and from certain forms 
of insanity, chiefly manias, and sometimes hypochondriacs, at times 
gorge themselves with food and drink. 

The presence of intestinal roundworms and tapeworms may give 
rise to overeating, though this by no means always follows. 

Overeating is apt to be carried to an injurious extent by the 
half-starved poor if they have sudden access to plenty, and by con- 
valescents from typhoid fever. 

Bulimia is a form of perverted sensation, causing inordinate 
craving for food. (See p. 328.) 

Overeating not only taxes the digestive system, but, what is often 
more serious, it throws too great a strain upon the glandular and 
excretory organs, especially the liver and kidneys, and if the habit 
is long continued, disease of the nature above described inevitably 
results. In like manner the overfed boiler becomes sooner burned 
out, and its fires choked with ashes which accumulate faster than 
they can be removed. Overeating, especially among the well-to-do, 
is the commonest dietetic error, and looking at the question in its 
broadest aspects, it is quite certain that the foundation for more 
disease is laid by this habit than by overdrinking. (See Alcohol, 
p. 225.) The former, indeed, sometimes conduces to the latter, 
and there are some examples of alcoholism in which the desire for 
drink is only aroused and fostered by previous excesses in eating. 

Overdrinking, except of alcohol (which is considered under the 
heading of Alcoholism), is not common, and is mainly confined to 
the excessive consumption of tea and coffee, which results in in- 
somnia, cardiac palpitations, and various neuroses. Dilatation of 
the stomach has been attributed in some cases to overindulgence 
in mineral waters, but such instances are very unusual. Polyuria 
and diabetes insipidus have also been ascribed to the abnormal con- 
sumption of fluids, but without strong proof. Excessive use of milk- 
as a beverage usually results in " biliousness " and constipation, but 
for the reason that it is really a solid food — that is, it becomes such 



368 DISEASES CAUSED BY DIETETIC ERRORS 

immediately on entering the stomach. Thirst is often extreme in 
fevers, diabetes, and other conditions, but the drinking of exception- 
ally large quantities of water is by no means always harmful, and it 
is often desirable to recommend it as a diluent and diuretic. The 
propriety of restricting its use in dropsies, gastric disorders, etc., 
will be considered under the appropriate headings. (See Gastric 
Catarrh, Ascites, Diabetes.) 

III. Food in itself Wholesome, but which is Injurious 

BECAUSE THE INGREDIENTS ARE NOT PROPERLY BALANCED 

Such diet may produce anaemia, from lack of meat or other 
animal food; scurvy, from preponderance of salt meat and fish and 
lack of fresh fruits and vegetables ; rickets and marasmus, from 
errors in infant feeding, such as excess of amylaceous and lack of 
animal food, necessary salts, etc. ; acne, or eczema, from food too 
rich in fats ; constipation, from a too nutritious and concentrated 
diet ; gout from various dietetic errors. 

The belief is held by some authorities that a diet of coarse cereals 
and vegetables favours the development of chronic arteritis. (See 
Vegetarianism, p. 35.) 

IV. Food containing Parasites or their Embryos 

Food sometimes serves as the medium for the introduction of 
parasites or their embryos, such as the tapeworm, roundworm, echi- 
nococcus, and trichina. 

In many cases the source of infection is found in the consumption 
of raw or very imperfectly cooked swine flesh and other meats used 
in the manufacture of sausages and similar preparations which are 
carelessly handled and come in contact with the viscera of the ani- 
mals in which the parasites or embryos reside in some intermediate 
stage of development. Another possible source of infection, espe- 
cially of intestinal worm larvae, is in the excrement of animals, which 
is permitted to pollute raw vegetables growing upon the ground. 
Manure is freely spread about, and dogs infested with worms, or a 
casual pig allowed at large in a vegetable garden, may contaminate 
by their faeces such vegetables as grow low upon the ground and 
are usually eaten raw, as lettuce, celery, cabbage, etc. Fortu- 
nately, this is by no means a common source of infection, but it 
is well to remember that several diseases have been definitely 
traced to such a source, and this explains the occasional presence of 
tapeworms in people who never eat raw meats, ham, or sausage, or 
the flesh of swine in any form. No animal should ever be allowed 
to roam in a vegetable garden. Other varieties of parasites or their 
larvae may occasionally be introduced with the food or water, such, 



INTESTINAL WORMS 369 

for example, as the Dracimculus medinensis, which produces the 
Guinea-worm disease, or Dracontiasis, the larvae of which are some- 
times swallowed in drinking water by the natives of parts of Africa 
.and the East Indies. 

INTESTINAL WORMS 

The presence of intestinal worms, such as the roundworm, 
Ascaris lumbricoides, and various species of cestodes or tapeworms, 
requires no special dietetic care beyond the preventive treatment of 
avoiding raw or imperfectly cooked flesh and submitting to a period 
of starvation for twenty-four hours, in order that the intestine may 
be completely emptied of food before an anthelmintic is given, so 
that it may more certainly reach the worms. 

There are two principal varieties of tapeworm in man, besides 
four or five others, which are very rarely present in the intestine, 
being derived from the lower animals through habits of filth or 
carelessness in preparing food. 

Of these two varieties, the commonest in this country is the Tcenia 
saginata, or mediocanellata ; the other, the pork tapeworm, or Tcenia 
solium, is more often found in Europe and Asia. The larval stages 
of Tcenia solium and Tcenia echinococcus also are observed in man, and, 
according to C. W. Stiles, one half the persons affected by the latter 
die within five years. H. O. Sommer has collected 100 cases of 
echinococcus (hydatid) disease in this country. The larvae are de- 
rived from the dog. 

The Tcenia mediocanellata is a segmented worm, having a large 
square head presenting four suckers, by which it maintains its hold 
upon the intestinal mucosa without the aid of hooklets. The seg- 
ments increase very slowly in size behind the head, and finally attain 
a breadth of eight to ten millimetres and a length of seventeen to 
eighteen millimetres, while the whole animal may reach a length of 
twenty feet, or even become longer than the intestine. Fragments 
of the worm are constantly breaking off, compressed by the waste 
matter of the food, and with it are swept out of the gut. The larvae 
live in swine. 

The Tcenia solium is not so long as the mediocanellata, measuring 
usually from six to twelve feet. The head, which is quite small, 
presents four suckers and several minute hooks, which enable the 
animal to secure a firm hold upon the mucous membrane. Behind 
the head are a series of segments, many hundred in number, con- 
stituting the body. They gradually increase in size, and the larger 
ones contain male and female organs of generation, each segment 
being supplied with both varieties. The larger segments attain a 
size of seven to eight millimetres by ten millimetres. Each mature 
segment contains an enormous number of ova — often several thou- 
sand — and in about three months, when the worm has reached its 



370 DISEASES CAUSED BY DIETETIC ERRORS 

full size, the segments, which are narrower and smaller than those of 
mediocanellata, are continually breaking off and passing out with the 
faeces. Pigs eat the ova, and digest them. The ova consist of shells 
which contain minute embryos with six hooklets. The embryos 
make their way into the viscera or muscles of the animal, where 
they lodge and develop to form the larvae or cysticerci, called also 
" measles." If the measled hog meat is eaten by man, and im- 
perfectly cooked, the cysticerci develop with the intestinal worms 
above described. 

The worms infest man at all ages, from early childhood up. 
They may cause no symptoms, but sometimes give rise to a raven- 
ous appetite, as they interfere with intestinal digestion and absorp- 
tion. They occasionally excite reflex nervous disturbances. Their 
presence is made certain by the finding of either the ova or the 
complete segments in various lengths in the stools. 

Treatment. — The patient should be put upon very short rations 
for two days, during which time the bowels must be well emptied. 
The evening before giving the vermifuge the patient should take a 
light supper of bread and milk or a sandwich, and that night a brisk 
cathartic. It is best to give the medicine the next morning fasting. 
By this means the intestines become almost empty, and the head of 
the worm is left unprotected, so that whatever remedy is used to 
kill it will make it loosen its hold. Another laxative may be given 
a few hours later, and if the patient eats bulky food, such as bread 
and potatoes, for a day or two, and keeps the bowels active, the 
worm may be completely dislodged and crowded out. The stools 
must be floated in water and closely examined for the head, for if 
this is not obtained the worm is sure to grow again in three or four 
months. There are many taeniacides. One of the least disagree- 
able and most efficient when properly administered is pumpkin seed. 
The seeds should be husked, and three ounces may be pounded in a 
mortar, macerated, mixed with honey into a paste, and eaten spread 
like jam upon a thin slice of bread. 



TRICHINOSIS 

Etiology. — Trichinosis is a parasitic disease produced by the 
embryos of a worm, the Trichina spiralis, which work their way 
into the voluntary muscles and there become embedded. Among 
the parasites liable to be eaten with raw meats this one is by far the 
worst and most fatal in its effects. The habitat of the adult worm 
is the small intestine. During the emigration of the embryos into 
the voluntary muscles a group of characteristic symptoms is pro- 
duced. The parasites have the following appearance : The adult 
male measures 1.5 millimetre in length; the female is from two to 
two and a half times as long. The embryo is 0.6 to 1.0 millimetre 



TRICHINOSIS 371 

in length, and when at rest, encapsulated in the muscle, is coiled in 
a spiral. It has a blunt tail and a sharp head. The adult male has 
two small projections from the caudal end. The ovoid capsule first 
appears translucent, but later, from the deposition of salts of lime, 
it becomes opaque. 

Infection in man is caused by the eating of ham and pork from 
hogs whose bodies contain the parasite. Among these animals it is 
of quite frequent occurrence. It is also spread through the agency 
of rats, which are eaten by hogs (Dock). 

Natural History of the Parasite. — After eating flesh which con- 
tains the embryos the process of digestion dissolves their capsules, 
and they are liberated, passing into the small intestine, where, with 
the presence of the favourable conditions of warmth, moisture, and 
food, they reach their adult growth in from three to six days. Rapid 
reproduction takes place in the intestine, and the number of young 
produced by a single female worm varies up to at least a thousand. 
In a week or more after the ingestion of the parasites the newly 
developed embryos pass out through the intestinal wall and mesen- 
tery, seeking the muscles, which they enter ; they then work their 
way through the connective tissue between the fasciculi or the sepa- 
rate muscle fibres, and finally enter the latter, where a fortnight's 
further development produces the complete muscle form. 

The observations of Askanazy point to the conclusion that the 
adult female deposits the embryos within the walls of the intestinal 
villi, not setting them free in the intestine, as originally supposed. 
From the villi they penetrate the muscles, as above stated. 

Thornbury reported at the Buffalo Academy of Medicine the 
results of analysis of 500 cases of infected swine. In these animals 
the parasite was found in the diaphragm 400 times, in the loin 290 
times, and in the neck 170 times. " The point of predilection there- 
fore appears to be the diaphragm. This is explained by its close 
proximity to the digestive tract, from which the trichinae primarily 
bore." In three cases in man which he examined the trichinae were 
found principally in the extremities, " one microscope slide from 
the biceps of an arm containing fifty of the parasites." They were 
also present in the diaphragm, intercostal and abdominal muscles. 

The embryos, when lodged in the muscle fibres, act as foreign 
bodies or irritants and excite an interstitial myositis with the forma- 
tion of a capsule around each embryo. One embryo may be lodged 
in a single capsule. Once within the muscle fibres, embryos remain 
without change until the capsule, the completion of which requires 
about six weeks, is in some way destroyed. After formation of the 
capsule a precipitation of lime salts occurs slowly within it for four 
or five months. The embryos, thus securely protected in a strong 
envelope, may retain their vitality for many years, and it is claimed 
that they have survived for at least two decades, but the worms 



37 2 DISEASES CAUSED BY DIETETIC ERRORS 

themselves not infrequently become calcified. Other animals be- 
sides hogs may harbour this parasite, among which are the rat, cat, 
mouse, and fox, and it can be artificially inoculated. 

Prophylaxis. — The prevention of trichinosis should consist in 
the more careful feeding of swine upon grain instead of offal, and 
for man the only absolute prevention is the extremely thorough 
cooking of all swine flesh, for a temperature of 140 F. is fatal to 
the embryos. Smoking and pickling is also preventive. 

" In the usual curing solutions trichinae are killed within six 
weeks in thin pieces of meat, but in thick pieces they can exist as 
long as four months " (Dock). 

The presence of the parasites in countless numbers in the flesh 
of the hog may give rise to no symptoms of any kind in the animal, 
and it is this fact which makes the eating of raw ham, pork, and 
sausages particularly dangerous unless the meat of the animals killed 
has been subjected to a searching microscopic examination. It is 
the safest rule never to eat such meats. The difficulty of detecting 
the parasite in the hog is considerably increased by the fact that the 
calcification is very much slower than it is in man, so that the worms 
are more readily overlooked. The parasites fortunately are com- 
pletely killed by boiling for some time the meat which contains 
them, but pickling or corning meat or smoking ham and bacon are 
not necessarily fatal to them. 

Frequency. — Cases of trichinosis are occasionally reported in 
this country chiefly among the Germans, whose fondness for raw 
ham and a variety of sausages is well known. Osier reports the 
finding of 456 cases, including 122 deaths recorded in America. 
Many persons are often simultaneously affected from eating the 
meat of the same animal, thus giving the disease the false character 
of an epidemic. 

Symptoms. — The symptoms vary with the number of parasites 
which have been eaten. If very few are ingested, the embryos are 
not reproduced in sufficient number to give rise to any symptoms. 
Usually, however, they are well marked, and embrace a stage of 
gastro-intestinal irritation followed by systemic infection. The pa- 
tient, three or four days after eating raw pork or ham, suffers from 
more or less severe abdominal cramps, with anorexia, vomiting, and 
diarrhoea. The latter occasionally becomes severe. General mus- 
cular prostration is also present, and there may be chills. In a 
number of cases the gastro-intestinal symptoms may not be severe 
enough to attract attention, and the first symptoms are those of 
general infection, which develop at the commencement of the second 
week. There is an increase of temperature, amounting to 103 or 
104 F., of an intermittent or remittent character. As soon as 
the embryos have extensively penetrated the muscles they give 
rise to great local pain and tenderness, accompanied by swelling 



TRICHINOSIS 373 

and tension of all the muscles affected. The patient naturally 
assumes the position in which there will be the least strain upon 
the muscles. 

These symptoms increase in intensity, and general cedema is apt 
to follow, which may appear first in the face. When certain muscles 
are implicated more serious symptoms may result. If the diaphragm 
is invaded or other muscles of respiration, there may be extreme 
or even fatal dyspnoea. If the parasites reach the muscles of the 
face, jaw, and pharynx, mastication and deglutition become difficult 
or impossible. There is more or less itching and burning of the skin 
and perspiration. Urticaria has been observed ; anaemia and a maras- 
mic condition eventually develop in a majority of cases, and marked 
eosinophilia amounting to 30 or 40 per cent is observed in the blood 
in this type as it is in other varieties of intestinal parasitic disease. 
There is comparatively little disturbance of the nervous system, and 
patients are usually conscious until the time of death, but in some in- 
stances a typhoid state supervenes with delirium. The other symp- 
toms which have been reported as occasionally present are loss of 
tendon reflex, bronchitis, pneumonia, pleurisy, albuminuria, and 
polyuria. 

Prognosis. — Mild cases may end in recovery within a fortnight. 
In severe cases in which there has been great prostration and ema- 
ciation convalescence is retarded for many weeks. 

Children are more apt to recover than adults, but the outlook 
depends chiefly upon the number of parasites ingested. Cases pre- 
senting severe diarrhoea are more likely to end favourably, probably 
because some of the parasites are eliminated in this way. 

Mortality. — The greatest mortality occurs between the fourth 
and sixth week. The causes of death may be exhaustion from 
choleraic discharges, dyspnoea, and inability to swallow. In pro- 
tracted cases inanition results. 

Autopsies show that but few organs aside from the muscles are 
affected by anatomical lesions. Cohnheim observed fatty degenera- 
tion of the liver and enlargement of the mesenteric glands. The 
muscles present the appearances of lesions of acute interstitial myo- 
sitis around the capsules of the embryos. 

Diagnosis. — The affection differs from acute rheumatism in the 
absence of swelling in the joints and the much greater local tender- 
ness along the surface of the muscles. The latter are exceedingly 
painful both to pressure and voluntary movement. The disease in 
its protracted form has-been mistaken for enteric fever, and un- 
doubtedly it has many times escaped detection. The most valuable 
features in determining the diagnosis are the extreme tenderness to 
pressure of the muscles, their swollen condition, and the general 
oedema and dyspnoea. Under cocaine anaesthesia a small piece of 
muscle may be excised from the arm or thigh for microscopic exam- 



374 DISEASES CAUSED BY DIETETIC ERRORS 

ination. Osier advises searching the stools for the parasites, which 
may be found with a low-power lens as glistening threads. 

Treatment. — The basis of treatment is to at once evacuate the 
alimentary canal, providing the fact of eating the infected meat is 
known within a day or two. Diarrhoea should not be checked. If 
constipation exists, a strong purgative of calomel and jalap or castor 
oil should be administered. When systemic symptoms develop, the 
treatment must be purely symptomatic, because there is no known 
remedy which will reach and destroy the trichinse. Every effort 
must be made to support the strength of the patient until the em- 
bryos have become encysted, after which the acute symptoms will 
subside of themselves. 



V. Food containing Ptomaines 

Ptomaines are substances resembling alkaloids which are formed 
in the alimentary canal by the decomposition or putrefaction of ni- 
trogenous foods. They may also form in such food outside of the 
body. This decomposition is the result of the action of certain 
micro-organisms simultaneously first described by Gautier in France 
and Selim in Bologna. It is at present believed that the constitu- 
tional symptoms observed in many infectious diseases are caused by 
similar poisons called toxins, which originate in the blood and 
other tissues of the body through the action of specific germs. The 
artificial cultivation of micro-organisms has proved that they are 
capable of forming substances which have distinct physiological 
actions that are sometimes highly poisonous. Many of these micro- 
organisms flourish in beef juice, milk, and various solutions of ni- 
trogenous material ; and in the alimentary canal, when such food is 
taken, all the most favourable conditions are present for the devel- 
opment of toxins. When the poisonous germs are ingested, their 
toxins are readily absorbed by the intestinal mucous membrane, 
and it is probable that ptomaine poisoning would occur very much 
oftener were it not that the liver, acting as it does as a gate- 
way for the admission of nutritive matter for the body, is capa- 
ble of destroying many poisons which enter it from the intestines 
through the branches of the portal vein. Corroboration of this 
statement is found in the fact that snake bites of the surface of the 
body may prove highly poisonous by immediate absorption of toxic 
material into the circulation, whereas snake poison may be swal- 
lowed with impunity, for if it is absorbed from the alimentary canal 
it is destroyed in the liver before reaching the nervous system. 

The same is true of the action of putrefying meat, which in very 
small quantities may not produce severe gastro-intestinal symptoms 
or constitutional disturbances, and yet if inoculated through a cut 
in the finger may cause symptoms of a violent septic character. 



POISONING BY MEAT OR GAME 375 

Richard (Diseases of Modern Life) reports a fatal case of poison- 
ing from eating tainted hare. The victim had had a small ulcer be- 
neath the tongue for some time, which became gangrenous after 
eating the meat, and which was the undoubted source of inocula- 
tion. 

Ptomaines may be developed from a variety of foods, but the 
principal ones from which poisoning from time to time occurs are 
spoiled meat, milk, shellfish, and fish. 

POISONING BY MEAT OR GAME . 

When meat has been kept too long exposed to the air, or when 
it has become contaminated in any manner with putrefactive bac- 
teria, it is unfit for food, yet if thoroughly cooked it may not 
be necessarily poisonous. This is the case with " high " game. 
The bacilli especially associated with meat poisoning are the Bacillus 
enteritidis of Gartner, and the anaerobic Bacillus butyricus of van 
Ermenghem. Dangerous and even fatal cases of systemic poison- 
ing by meat ptomaines have resulted from eating sausages, pork pie, 
ham, meat juice, beef, head-cheese, mutton, or veal. Two hundred 
and ninety-one severe cases of meat poisoning, one of which ended 
fatally, developed upon the U. S. transport City of Rio de Janeiro, 
in 1899, while proceeding from Honolulu to Manila. The putrefac- 
tive change may have already begun in the meat although it may not 
be apparent by an altered taste. Sausage poisoning is called botu- 
lism or allantiasis. 

It is a curious fact that certain persons have great toleration for 
tainted meats. Among civilised races, and especially in England, 
the use of " high " game and mutton is much less in vogue at pres- 
ent than formerly, but the Eskimos and many savage tribes in 
Africa eat with relish, and digest well, decomposing meat the mere 
odour of which nauseates a white man. Bishop Colenso stated that 
among the Zulus of Natal the synonym for heaven is " ubomi" which 
means " maggoty meat." The natives of Siam and Cambodia prefer 
to keep their fish until it has begun to putrefy. In some parts of 
China foul eggs several months old are enjoyed as a delicacy. 

Measly swine flesh rapidly decomposes, and the various processes 
of drying, smoking, and salting still leave it unfit for food. On 
the contrary, drying and smoking affect the superficial layers only, 
while the minor portion furnishes a culture medium for bacilli. 
Gluckmann has reported a case of poisoning by the Bacillus pro- 
teus vulgaris from eating cured ham. 

The meat of very young animals should never be eaten, and 
the sale of young or " bob " veal two or three weeks old is 
prohibited by law. It is indigestible, innutritious, and it readily 
decomposes. 
26 



37^ DISEASES CAUSED BY DIETETIC ERRORS 

Symptoms. — The symptoms of meat poisoning from these various 
substances are substantially the same in each case, being those of 
severe gastro-intestinal irritation, but in bad cases they are accom- 
panied by dangerous collapse. The symptoms may follow almost 
immediately or after an interval of four or five or more hours. The 
former is much better for the patient, for the sooner vomiting and 
diarrhoea relieve the alimentary canal of the toxigenic material, the 
greater the chance of recovery. The symptoms usually begin with 
suddenness and violence, but they may be preceded by malaise, nau- 
sea, lassitude, and mild abdominal cramps. The sudden onset is 
ushered in by rigours with vertigo or faintness, or violent head- 
ache. Exceptionally there is dyspnoea, and there may be cold per- 
spiration and sudden severe pains in the epigastrium or in the thorax, 
especially between the shoulders. Intense thirst has also been ob- 
served. Soon after one or more of these symptoms have appeared 
there is violent colicky pain in the bowels, accompanied by retch- 
ing and vomiting, sometimes haematemesis, and profuse watery 
diarrhoea. There is an extreme degree of muscular prostration 
which comes on suddenly and prevents the patient from standing. 
It may be due to the abdominal pain, but it also occurs independ- 
ently. The tongue is dry and coated with a thick brownish-yellow 
fur on the dorsum, but the margins are of a bright red with distinct 
papillae. Fever is usually present, and the temperature may rise to 
103. 5 or 104° F., although the skin may feel cold and moist. The 
pulse is somewhat accelerated and the rate may reach 130 or 140. 

Occasional symptoms which have been noted by Ballard are 
severe cramps in the legs and arms, convulsive twitching of the mus- 
cles of the face and hands, stiffness in the joints, and various abnor- 
malities of sensation, such as numbness, tingling, and flashes of heat 
and cold in the extremities. There may also "be drowsiness, photo- 
phobia, and, in the worst cases, insomnia, nervous excitement, or 
mild delirium. If the poison results fatally, the prostration increases, 
the pulse grows rapid and feeble, the watery evacuations are uncon- 
trollable, and rapid emaciation ensues. The patient becomes cya- 
notic and passes into a state of collapse resembling that of the last 
stage of cholera. 

The poisoning presents all degrees of severity, depending on the 
amount of the tainted food which has been taken, the nature of the 
putrefactive process, and the condition of the alimentary canal at 
the time. In mild cases, more or less abdominal pain, vomiting, 
diarrhoea, and headache, with slight prostration, are the only symp- 
toms. In the more severe rases, if convalescence follows the attack, 
it is prolonged, and the weakness of the patient may be fully as 
great as after some of the severe infectious fevers affecting the ali- 
mentary canal, such as cholera or yellow fever. In cases in which 
the symptoms develop very slowly, after an interval of a day or 



POISONING BY MILK, CREAM, ICE CREAM, AND CHEESE 377 

more the nervous symptoms are apt to predominate over those of 
the gastro-enteric system. There are painful muscular cramps, 
dyspnoea, aphonia, delirium, and palpitation. This variety of poi- 
soning is extremely dangerous. 

Diagnosis. — The diagnosis is almost always obtainable from the 
history of the case in connection with the symptoms above de- 
scribed, and when canned food has been eaten, the only difficulty 
consists in determining whether the poisoning is the result of eating 
tainted meat or of acute metallic poisoning from chloride of zinc, 
tin, or lead used in the process of tinning and soldering the cans 
(see p. 278). 



POISONING BY MILK, CREAM, ICE CREAM, AND CHEESE 

Poisoning by plain milk is less common than from certain vari- 
eties of cheese and from cream. When ice cream is made in large 
quantities, the cream is allowed to accumulate, and if a portion of it 
becomes infected with pathogenic organisms it will soon convert 
the whole mass into highly poisonous material. In a small town in 
Indiana, in 1900, over one hundred persons were seriously poisoned 
by ice cream from soiled cans. Many other such casualties have 
been observed of late years. Sixty-seven men, at the San Juan 
garrison in Porto Rico, were poisoned in 1900 by condensed milk. 
In the U. S. Surgeon-General's report for 1900, the symptoms are 
described as follows by Assistant Surgeon George M. Wells, 
U. S. A. : 

" The symptoms were persistent vomiting, severe cramps in the 
stomach, purging, great prostration, dilatation of the pupils, head- 
ache, clammy perspiration, chilliness, and great thirst. The stomach 
in each case was washed out by means of the stomach tube. In 
some cases the stomach was empty, and nothing but water and 
mucus came away ; in others the washings were tinged with bile, 
and in others again a moderate amount of food that had been 
eaten for breakfast was washed out, but in no case was the stomach 
overdistended or even full. The vomiting was controlled in several 
instances by the washing out of the stomach, but in many it per- 
sisted for several hours afterwards. The prostration was so great 
that some of the patients fainted before reaching the ward. A large 
number vomited blood in small clots, in most instances mixed with 
nothing but mucus, showing that the haemorrhage had not taken 
place until after the contents of the stomach had been expelled. 
Purging began in most before the vomiting had ceased, and con- 
tinued for twelve to fifteen hours. At first the stools were natu- 
ral, soon watery, afterwards becoming mucous and blood tinged. 
Cramps in the voluntary muscles were mild in some, but other pa- 
tients writhed in agony, their sufferings being relieved only after 



378 DISEASES CAUSED BY DIETETIC ERRORS 

thorough kneading and massage by the hospital attendants. Forty 
were discharged from hospital on the following morning ; the others 
from day to day until the fifth morning, when all were returned 
to duty." 

Vaughan and Novy in this country have thoroughly studied the 
whole subject of ptomaine poisoning, and Vaughan has isolated from 
cheese and ice cream a toxin to which he has given the name of 
" tyrotoxicon," and in Michigan in i883~'84 nearly three hundred 
instances of cheese poisoning were collected by him. In 1890 he 
isolated three proteid substances from germ cultures from the in- 
testines of infants having milk infection. The symptoms of tyro- 
toxicon poisoning are substantially the same with those of meat 
poisoning, consisting of severe gastro-intestinal disturbance with 
collapse. 

This toxin produces almost immediately after ingestion by a 
previously healthy infant violent symptoms of cholera morbus, 
which prove fatal in a few hours unless the poison can be eliminated. 
(See Cholera Morbus Treatment.) Of this poison Vaughan says : 
" Post-mortem examination shows but little change. [There is 
time for but little in fatal cases.] The mucous membrane of the 
small intestine is bleached and softened, and possibly deprived here 
and there of its superficial epithelium." 

The poison apparently acts somewhat as the toxin of Asiatic 
cholera, by absorption from the intestinal wall, and by violently 
deranging the nervous and vascular systems, producing sudden and 
extreme loss of fluid from the body through osmosis into the in- 
testine. 

POISONING BY SHELLFISH AND FISH 

Poisoning by shellfish and fish results from infection with pto- 
maines developed by micro-organisms, as in cases of milk and meat 
poisoning. In addition, it must be remembered that there are a 
number of persons who, from idiosyncrasy, possess an extreme de- 
gree of sensitiveness to the action of shellfish of all kinds. To 
such persons the eating of clam broth or raw oysters, crabs or lob- 
sters, may give rise to violent outbreaks of urticaria or eczema, or 
produce severe headache, nausea, and vomiting. It is scarcely prob- 
able that these cases are due to the same source as those of true 
ptomaine poisoning, for they occur when the shellfish have been 
eaten in perfectly fresh condition ; the symptoms, moreover, are 
usually less violent than those caused by ptomaines, and similar 
effects are produced in some people by certain vegetables and fruits, 
like the strawberry. Among shellfish the mussel furnishes the most 
violent poison. This substance Brieger has isolated under the name 
of " mytilotoxin." It develops particularly in the liver of the ani- 
mal. The intensity of the poison depends somewhat upon the local- 



FOOD CONTAINING OTHER POISONS THAN PTOMAINES 379 

ity in which the animal has lived and fed. The same mussels may 
become non-toxic in different waters. The name ichthysmus is ap- 
plied to fish poisoning in general. 

Symptoms. — The symptoms of poisoning from eating raw fish 
or cooked mussels in which ptomaines have developed are somewhat 
different from those of meat and milk poisoning in that they con- 
cern the nervous system with less gastro-intestinal disorder. For 
this reason the poison is very much more dangerous, and cases have 
been known to result fatally two hours after eating mussels. In 
such instances there may be no nausea, vomiting, or fever, but there 
is sudden and extreme prostration, with numbness, faintness, cold- 
ness of surface, dilatation of the pupils, double vision, restlessness, 
nervousness, anxiety, and a feeble and very rapid pulse. In France 
hard-roed herrings have caused such symptoms. Decomposing oys- 
ters and fish may also produce symptoms of gastro-intestinal poison- 
ing resembling those from the use of bad meat. The salted sturgeon 
which is eaten extensively as a food in parts of Russia has caused 
death from its decomposition, and a variety of fishes both in Euro- 
pean and Eastern waters are capable of developing very active tox- 
ins. In Russia poisoning has been produced by eating the ova of 
the pike, barbel, and perch, and decomposed sturgeon roe (caviare). 
Portions of the porpoise, eaten in China, may prove poisonous un- 
less thoroughly boiled. The mackerel family has three species which 
are poisonous, namely the jurel, bonito, and chicaro. They are 
found in the West Indies. Two species of herring are poisonous ; 
one of them, the meletta, taken along the Atlantic coast from Florida 
to New York, has caused several fatal cases of poisoning. 

VI. Food containing other Poisons than Ptomaines- 
Grain Poisoning, etc. 

It sometimes happens that flesh becomes poisonous from the 
animal having fed upon some noxious substance shortly before it 
was killed. The flesh of pigs fed on garbage may cause diarrhoea 
(Parkes). It is a well-known fact that the flavour and digestibility 
of game, and even fish, varies much with the season of the year and 
the consequent nature of the food which the animal has had. Oys- 
ters are not wholesome food from May to September, or in " the 
months without an R." Cow's milk becomes unhealthful for infants 
when the animal eats improper food, and instances have been re- 
ported — although, fortunately, they are very exceptional — of illness 
of adults caused by eating meat which had been poisoned during the 
animal's life, as in the case of a sick ox to which a large dose of 
tartar emetic was given. The animal died, and the meat subse- 
quently was found to contain enough of the substance to severely 
poison those who ate it. 



380 DISEASES CAUSED BY DIETETIC ERRORS 

Game sometimes disagrees on account of the nature of the food 
upon which the animal has previously been living. This is said to 
be particularly true of the grouse in various parts of the country at 
some seasons of the year. The laurel buds act in this manner. 
Hares fed upon rhododendron are poisonous (Letheby). 

A curious instance of poisoning from eating turkey meat was 
reported by Seelye, of Amherst, Mass. Several young women at 
a boarding school showed symptoms of atropine poisoning after 
eating a bird which had fed upon the deadly nightshade berries. 



GRAIN POISONING 

Old unripe grain and mouldy flour develop poisons from decom- 
position of their gluten. 

Ergotism. — The fungus known as ergot, or Claviceps purpurea, 
grows upon rye, and in Europe the careless admixture of this sub- 
stance with grain in the preparation of flour has several times re- 
sulted in violent symptoms of poisoning. Collectively the symp- 
toms are described as " ergotism," and they are commonly divided 
into two varieties, the gangrenous and the convulsive. The ergot- 
containing flour or meal must have been eaten for a considerable 
time, as a rule, in order to develop the symptoms. 

Ergot is sometimes employed too freely in medicine. In appro- 
priate cases it may be given in considerable quantity for a brief 
period without exciting toxic symptoms. When, however, its use 
is prolonged beyond a few days, serious poisoning results. 

In the gangrenous form of ergotism the early symptoms are 
referable to local vasomotor disturbances, affecting principally the 
extremities. These symptoms are anaesthesia, numbness, prickling 
pain, and spasmodic twitching of the muscles, with an impeded blood 
flow due to vasoconstriction. In the convulsive variety the nervous 
system is profoundly disturbed. After a period of indefinite symp- 
toms, such as lassitude, headache, and prickling sensations, spasms 
of the muscles with contractures begin. The spasms may be inter- 
mittent, or may assume a tetanic character, lasting sometimes 
through many days ; the arms are strongly flexed and the legs and 
toes are extended. Spasmodic rigidity of the muscles may give 
place to violent convulsions, which become general and fatal. There 
is sometimes slight fever, and in the chronic cases melancholia or 
dementia results. Delirium also is sometimes present. In cases 
reported by Siemens and Tuzzek the posterior columns of the spinal 
cord were found sclerosed. 

Lathyrism. — A grain called the chick-pea vetch is sometimes used 
for the adulteration of flour from various cereals. Several varieties 
are used which have a similar effect to ergot in producing a condi- 
tion of spastic rigidity in the lower extremities. This form of poi- 



FOOD ADULTERATION 38 1 

soning has been observed in India by James Irving, and by others in 
Italy and France. It is, however, rare, and but little is known as to 
the exact nature of the lesions. 

Pellagra. — Pellagra is a functional disturbance caused by eating 
fermented unripe maize or Indian corn, made into polenta. It is 
unknown in this country, but prevails in the south of Europe, in 
portions of Spain, France, and Italy. The first symptoms noticed 
are those of dyspepsia with more or less nervousness, insomnia, and 
debility. These symptoms are followed by an eruption, the pella- 
gral erythema, which develops in the spring. After the eruption 
has lasted for some time, the skin becomes very dry and extensive 
desquamation ensues accompanied by burning pains, or, if neglected, 
the surface may become incrusted with areas of suppuration. With 
the appearance of the eruption the dyspeptic symptoms are increased, 
and there may be salivation and severe diarrhoea. The disease lasts 
in greater or less severity for several months and ends in slow 
convalescence, or else, in the worst forms, the nervous system is 
involved and emaciation, headache, convulsions, delirium, and pa- 
ralysis of the legs may appear. The peasants who eat this spoiled 
food sometimes hftve severe attacks in successive years, and melan- 
cholia and suicidal mania have been observed among them. There 
are no definite lesions other than those of malnutrition, such as 
fatty degeneration of various organs (Arnold). 

The disease is not contagious, and it is said to be preventable 
by adding salt to the cornmeal ; but salt is a Government monopoly 
in Italy. The peasants resist the tax upon it, and, through prejudice 
as much as through ignorance and poverty, they fail to make use 
of it. 

VII. Food Adulteration 

Food adulteration consists of : 1. The addition of deleterious sub- 
stances. 2. Fraudulent substitution of cheaper articles of food or the 
sale of food not as fresh or good as it is represented. 

A. J. Wedderburn, in a report to the United States Department 
of Agriculture, makes the statement that of all food products sold 
in this country, 15 per cent is adulterated, but only 2 per cent is 
deleterious. 

With the exception of milk and alcoholic beverages, the adul- 
teration of foods in the United States is of comparatively little 
importance from any harmful influence it may have upon health. 
Its moral are often worse than its physical aspects. 

In this country almost all food products are so abundant and 
cheap that adulteration would be too expensive, and it offers small 
temptation to unscrupulous dealers. There are, however, certain 
articles of diet which form exceptions to this statement, although 
the adulteration is more often merely fraudulent than a menace to 



382 



DISEASES CAUSED BY DIETETIC ERRORS 



health. These articles are included in the following table of exam- 
inations made in a single State (Kentucky) by the Agricultural Ex- 
periment Station. Forty per cent of all samples taken were found 
adulterated. 



Kind and Number of Scmiftles collected from Jujie ij, i8g8, to December 

31, 1899 



Articles Sampled. 



Baking powder 

Butter 

Canned goods , 

Catsups, pickles, etc , 

Coffee 

Cornstarch , 

Flour (wheat) 

Jellies, preserves, etc 

Lard 

Milk (sweet and buttermilk) 

Milk colour , 

Mince-meat „ 

Oleomargarine. 

Olive oil 

Pepper, spices, etc 

Sweet cider and grape juice. 

Soda (cooking soda) 

Sirups, honey, and sugar.. . . 
Vinegar 

Total 



Not found 
adulterated. 


Adulterated. 


II 


45 


Il8 


29 


6 




12 


45 


2 


1 


I 




20 




5 


18 


29 


n 


115 


35 


1 






7 


2 


16 


1 


1 


3 


11 




3 


3 




4i 


9 


67 


59 


437 


290 



Total. 



56 
147 

6 

57 

3 

20 

23 

40 

150 

1 

7 
18 

2 
14 

3 

3 

50 

126 



727 



At the Connecticut Agricultural Experiment Station, 41 \ per 
cent of 574 samples of spices were found adulterated, and over 25 
per cent of coffee samples were adulterated (1899). 

The object of adulteration of food — namely, to cheapen cost of 
production— is attained by (a) increasing the bulk, (b) altering the 
appearance, and (c) giving false strength. 

In many States stringent laws have been enacted against all adul- 
teration of food products, beverages, and drugs, but the ingenuity 
of manufacturers and dealers in evading them necessitates the con- 
stant vigilance of the experts of health boards. 

Among the common adulterations may be mentioned the follow- 
ing : Isinglass adulterated with gelatin ; wheat flour with bran or 
cowpeas ; powdered sugar with barium sulphate ; mustard with flour 
and turmeric ; " essences " of peppermint, cinnamon, etc., with poi- 
sonous wood alcohol ; distilled coloured vinegar sold as cider vine- 
gar ; pickles adulterated with iron and copper (Massachusetts State 
Board of Health Reports) ; oleomargarine sold as butter ; ground 
spices are adulterated with cocoanut shells, rice, flour, and ashes 
(Ohio Dairy and Food Commission) ; water, sugar, and tartaric acid 
are sold as lemonade. Wines and liquors are sometimes adulterated 



FOOD ADULTERATION 383 

with alum, baryta, caustic lime, salts of lead, salicylic acid, and pig- 
ments, especially haematoxylon. 

Candies are adulterated with terra alba, kaolin, and various pig- 
ments, and the different chewing gums, gum drops, etc., are largely 
made with petroleum-paraffin products. 

Most of the maple sugar sold is made from glucose, and maple 
sirup is also derived from other sugars and artificially flavoured with 
extract of hickory bark (Wiley). 

Cotton-seed oil is often sold as olive oil. 

Nearly half the liquid honey sold is adulterated with glucose. 

Cocoa and chocolate are adulterated with both starch and 
sugar. 

Coffee is very extensively adulterated with sugar, caramel, pea 
meal, chicory, and saccharin extracts. Coffee berries are artificially 
made in moulds out of mixtures of starch, molasses, or caramel, 
chicory, etc. Baking powder is often adulterated. 

Prof. R. H. Chittenden, as a result of elaborate investigations 
made with a view to determine the effect upon digestion of borax and 
boric acid when added, as they often are, to preserve foods, con- 
cludes that " borax and boric acid, when present in moderate quan- 
tities, can have little or no deleterious effect upon the more impor- 
tant chemical processes of digestion. On the contrary, it would 
appear that the presence of these agents may, in some cases at least, 
even accelerate the normal digestive processes of the alimentary 
tract." 

Pigments. — Artificial colouring matters are added to foods, both 
to intentionally deceive and also merely to make different substances, 
such as preserved green vegetables, candies, or confections, appear 
more attractive to the eye. 

Formerly highly injurious copper or zinc salts were much used 
to colour canned peas and beans, and not infrequently they were 
found in poisonous quantities, but the green plant pigment chloro- 
phyll is so much cheaper, and is so abundant and harmless, that it 
has superseded them almost entirely since its introduction for this 
purpose in 1877. 

Ultramarine is much used to colour sirups ; safranin, eosin, fuch- 
sin, anilin violet, and many other anilins are employed in the manu- 
facture of candies, as is also cochineal. 

The pigments most in vogue to colour butter and cream are tur- 
meric, saffron, an orange pigment from the stigmas of a flower, sul- 
phonated anilin yellow, and annotto, a yellow pigment derived from 
the fruit of a South American tree. Annotto as used by dairymen 
to colour milk and cream is not harmful. To detect it, add a tea- 
spoonful of baking soda to a quart of the milk, and immerse in it 
a strip of unglazed paper. In a few hours the latter becomes orange- 
coloured if annotto is present (Leffmann). 



384 DISEASES CAUSED BY DIETETIC ERRORS 

Salicylic Acid. — The French Commission of Public Hygiene 
made an exhaustive investigation of the subject of adulteration of 
bottled beer, cider, milk, grape juice, and other aliments with sali- 
cylic acid, which is mainly added to prevent decomposition. They 
reported that its daily use in the quantities employed for preservation 
is not harmful to healthy persons, but if renal or hepatic disease 
exists it may become so, for under these conditions it is not promptly 
eliminated. Used in any considerable quantity, it in time produces 
anaemia, as it does in rheumatism. 

Wiley found salicylic acid in seven out of ten samples of canned 
tomatoes bought in markets. Formic aldehyde is extensively em- 
ployed as a preservative of milk and other foods. 

Vaseline is sometimes used to adulterate butter for making pas- 
try and cakes. It does not become rancid, and is therefore difficult 
of detection. Fortunately, it is not especially harmful. 

TIN AND LEAD POISONING 

Both tin and lead poisoning may arise from the prolonged use 
of preserved meats, vegetables, or fruits. In tin cans the lead is 
derived from the action of various organic acids upon the solder 
(which in this country is usually 50 per cent lead), and the tin used 
for coating the inside of the can eventually is dissolved in a similar 
manner. (See also Canning, p. 278.) 

Of late years attention has been directed to this subject by chem- 
ists, and a number of cases are reported from time to time of serious 
metallic poisoning. As a general rule, if the canning is properly 
conducted and the meats or vegetables have not decomposed, there 
is no danger in their use provided they are thoroughly cooked, and 
provided also that the cans have not been kept too long. The 
amount of tin dissolved is directly proportionate to the age of the 
contents of the cans. The food in cans that have been unopened 
for two or three years is very apt to produce poisonous effects. 
Professor Bettink declares that malic acid is the solvent of the tin 
when fruits and vegetables are canned. 

Hehner examined many canned foods, and found tin present, in 
most of them as a stannous hydrate, which existed in sufficient quan- 
tity to be fatal when given to guinea pigs. 

Ungar and Bodlander have reported a number of cases of poison 
from canned asparagus. Tin present in such food in an insoluble 
form may be dissolved and absorbed during digestion. 

Professor Beckurts reported that a sulphate of tin is formed by 
the action of vegetable albuminoids or of meat albumin on the can. 
This is very liable to take place with canned asparagus, and two 
cases of severe poisoning of this nature have come under my per- 
sonal observation. Violent gastro-intestinal symptoms occurred, 



MILK INFECTION 385 

such as severe vomiting and diarrhoea, accompanied by faintness and 
vertigo. The symptoms came on two or three hours after eating the 
asparagus from cans which had been kept for a long time. 

Johnson (in The Medico-Legal Journal, vol. iii, p. 53) reports 
cases of dangerous poisoning from eating tinned tomatoes which 
were accompanied by symptoms of violent gastritis, stupor, and 
coma. 

Winckel reported the cases of 270 soldiers who had been made ill 
from eating lettuce and meat preserved in tins. In their cases it was 
estimated that the quantity of tin in solution was from 19 to 72 milli- 
grammes per kilogramme. Roos advises the coating of such cans on 
the inside with insoluble varnish, which prevents the albuminoids or 
vegetable acids from coming in contact with the tinned surface and 
dissolving the metal. He found upon opening a can of asparagus 
preserved for thirty-one years that the inside tin coating was wholly 
dissolved in the liquid. A can of beef preserved for eight years, 
weighing 976 grammes, contained yy milligrammes of oxide of tin, 
and a can of asparagus preserved only four months contained 11 
milligrammes of oxide of tin and 6 of copper. Preserved apples, 
corn, apricots, meats, and soups have also all been found to possess 
the same solvent action upon tin cans. This is almost entirely pre- 
vented in those instances in which a coating of varnish has been put 
over the tinned surface. 

Pears cooked in a tin stewpan have been known to cause severe 
poisoning. 

One hundred and fifty cases of severe metallic poisoning occurred 
among the soldiers of a Tyrolese regiment who ate food from a tin- 
lined copper kettle. 

In general, food cooked or allowed to stand for any length of 
time in either brass or copper vessels not kept absolutely clean is 
dangerous to life. 

VIII. Food containing Micro-organisms 

Recent developments in the study of micro-organisms conducted 
within the past decade have demonstrated very clearly the dangers 
of infection upon a large scale from consumption of meat, milk, and 
other foods contaminated by the germs of infectious diseases. 

MILK INFECTION 

Milk is an admirable culture medium for a great variety of germs, 
and some bacilli, like those of typhoid fever and tuberculosis, thrive 
particularly well in it. Moreover, its abundant and varied proteid 
material furnishes substance out of which to develop powerful toxins 
for absorption. 

The following are the chief diseases whose germs are capable of 



386 DISEASES CAUSED BY DIETETIC ERRORS 

being sometimes conveyed by milk : Tuberculosis, typhoid fever, 
cholera, diphtheria, scarlet fever. 

Milk, and food in general, should never be kept standing in an 
ice box or cellar near an open or defective drain, as it becomes 
rapidly tainted in noxious air. 



TUBERCULAR INFECTION THROUGH MILK AND MEAT 

Tubercular Milk Infection. — This matter is of special importance 
in regard to the danger of conveying tuberculosis to infants through 
raw milk. That this may happen is generally accepted as proved 
(although Koch, at the Tuberculosis Congress held in London in 
1901, made an emphatic statement to the contrary), and State boards 
of health m this country are everywhere endeavouring to secure 
proper legislative authority to inspect and condemn tuberculous 
cattle. 

Milk infected with tubercle bacilli when fed to animals has been 
shown to produce primary intestinal and mesenteric tuberculosis, 
and this may occur in infants. H. C. Ernst produced tuberculosis 
in pigs by feeding them milk from tubercular cows even when 
the latter had normal udders. Cow's milk may contain tubercle 
bacilli even when the disease is located in the lungs of the animal 
(Ernst). It is possible that this is the case w T ith the milk of tuber- 
cular mothers, although it is not yet an established fact. The danger 
to the infant is less in such cases, for the disease in the mother is 
usually recognised in time to discontinue breast nursing. 

It has been estimated in regard to the Eastern States that 15. per 
cent of the common dairy stock is tubercular. Stall-fed animals who 
live in filthy barns and get but little exercise show the largest per- 
centage of infection. In healthy adults the gastric juice may succeed 
in destroying tubercle bacilli swallowed with such food, and no doubt 
it often does so. Fortunately the milk of all tubercular cows does 
not contain the bacilli, but it is almost certain to do so when the 
udders become involved in the disease. In large dairies the cows 
should be given the tuberculin test once in six months, and if they 
respond should be condemned as milk producers. (Conference of 
State Boards of Health, 1898.) 

In infants who live largely upon raw milk, and whose gastric 
digestion is less vigorous than that of adults, mesenteric tubercu- 
losis is relatively more common. 

Tubercular Meat Infection. — Tubercular meat usually proves less 
virulent than raw milk, probably because it is subjected to thorough 
heat in cooking, but all the bacilli are not invariably killed by im- 
perfect cooking, and infected meat or milk should on no account 
be eaten. This fact is being gradually appreciated by the public, and 
meat inspection at abattoirs is now much better regulated by law and 



TUBERCULAR INFECTION THROUGH MILK AND MEAT 387 

supervised by local health boards than formerly ; but Billings says 
that " probably one half of one per cent of the beef sold in market 
comes from animals in whom tubercle existed at the time of death." 

All slaughtering should be done in public abattoirs under com- 
petent inspection, and not only should the animals be examined be- 
fore killing, but the meat should be inspected afterwards. 

The Bacillus tuberculosis has been found not only in the meat or 
muscle of the ainmal butchered, but in the liver, kidneys, and other 
viscera. It has also been seen in peripheral caseous nodules grow- 
ing upon fowls (Sibley), and barnyard fowls have been known to eat 
tuberculous sputum carelessly expectorated within their reach. The 
bacillus is not killed by salting meat nor always by its digestion in 
the stomach. Moreover, salt meat is not so thoroughly cooked as 
fresh meat, as a rule. 

Theobald Smith (Annual Report, Massachusetts State Board of 
Cattle Commissioners, 1897) says it is doubtful whether the muscles 
of cattle ever contain bacilli, but the latter are liable to be smeared 
over the meat by the butcher's knife fresh from cutting into a tuber- 
culous lymphatic gland or lung. According to this writer, there 
are several varieties of tubercle bacilli as found in different animals, 
which show decided differences in morphology and pathogenic ac- 
tivity, but their morbific processes appear to be substantially the 
same. He suggests that the bovine and human varieties may under 
some conditions pass into one another, but he denies that cattle are 
susceptible to human tuberculous sputum. He believes that the 
danger of infection of man through milk and meat is greatly exag- 
gerated, for while human tuberculosis has been decreasing for a 
whole generation, that of cattle, at least until very recently, has been 
on the increase. One or two curious cases are recorded of fowls 
dead of tuberculosis acquired by pecking at human tuberculous spu- 
tum, and Peter Paterson, of Glasgow, reports a death from eating 
tuberculous poultry. 

D. E. Salmon, Chief of the United States Bureau of Animal 
Industry, in a report covering the two years ending June 30, 1899, 
says: 

" The number of condemnations per 10,000 animals slaughtered 
was : 





Cattle. 


Sheep. 


Swine. 






22 
26 


7-5 
O.6 


24 
13 












Total 


48 


8.1 


37 









" Of the whole carcasses of cattle condemned 26 per cent were 
affected with actinomycosis and 36 per cent with tuberculosis. Of 



388 DISEASES CAUSED BY DIETETIC ERRORS 

the parts of carcasses of cattle condemned 13 per cent were affected 
with actinomycosis and 1 per cent with tuberculosis. Nevertheless 
these diseases are surprisingly rare, as only 8.1 carcasses per 10,000 
animals were condemned for tuberculosis, and 9.2 per 10,000 for 
actinomycosis. Tuberculosis is one of the principal diseases of 
swine, but is found only in 1.3 carcasses per 10,000 animals. Tuber- 
culosis in sheep is a rare disease. Including tuberculosis and pseudo- 
tuberculosis, which are given together in the reports, there are speci- 
fied but 6 per 100,000 sheep inspected. 

" The beef-cattle which come from large abattoirs are singularly 
free from tuberculosis, only 1 animal in 1,500 or 2,000 being affected 
to an extent to cause condemnation of any part of the carcass. Dairy 
cattle may be affected to the extent of 5 to 10 per cent ! In Europe, 
the slaughter-house statistics show from 20 to 50 per cent of all cattle 
slaughtered to be affected with tuberculosis." 

Other Infections. — Meat from animals dead of various acute dis- 
eases is sometimes eaten, and if well cooked it may be harmless, but 
it is not good food, and no part of any animal suffering from the 
foot-and-mouth disease (or cattle plague), rabies, glanders, actino- 
mycosis, anthrax, septicaemia, swine plague, sheep or cow pox, pneu- 
monia, trichinosis, or tuberculosis should ever be eaten. 

TYPHOID AND CHOLERA INFECTION 

Typhoid infection is undoubtedly conveyed through milk which 
has been diluted with water infected from a barnyard well or cess- 
pool, or which has been placed in cans rinsed in such water. Hankin 
describes cases of this fever derived from eating dahi, a curdled milk 
made by East Indian confectioners. Fraenkel found that typhoid 
bacilli may live in acid buttermilk. The typhoid bacillus may live 
for several days in fresh milk without multiplying. 

Three hundred and eighty-six cases from milk infection occurred 
at Stamford, Conn., in May, 1895. Another epidemic occurred in 
York, Pa., in 1899. 

At Coseley, near Birmingham, England, five cases of typhoid 
fever were traced to infection from ice cream. 

Typhoid infection through contaminated drinking water has been 
already mentioned (p. 39). Even brushing the teeth with such 
water or using it as ice may convey the bacilli into the body. 

INFECTION WITH TYPHOID-FEVER GERMS THROUGH EATING 

OYSTERS 

An epidemic of typhoid fever occurred at Wesleyan University 
in the latter part of November, 1894, which affected only certain 
students to the number of thirty, who had attended college-society 
suppers and ate raw oysters. A very thorough investigation was 



TYPHOID-FEVER GERMS THROUGH EATING OYSTERS 389 

made by Prof. H. W. Conn into the aetiology of the epidemic, and 
the following account of it was published in the New York Times on 
November 20, 1894: 

" The investigators at first ascertained that neither the water of 
the college well nor the milk supply had been the agent of infec- 
tion. Six college societies had given initiation suppers. All of the 
oysters eaten at these suppers had come from one dealer, who had 
obtained them from one oyster grower. At three of these suppers 
raw oysters were served, and all of the thirty victims had partaken 
of the oysters in this condition ; no one of those present at the other 
three suppers, where only cooked oysters were served, was attacked 
by the disease. These facts indicated that the germs of typhoid had 
been conveyed in the water and other matter which accompanied the 
raw oysters. How had that water and other matter become in- 
fected ? 

" The oyster grower, who lives on the shore of the Quinnipiac 
River, a stream which flows into New Haven harbour, had been in 
the habit of laying down his oysters for a day or two in the river, 
after taking them from the deep salt waters of the Sound and before 
putting them on the market. At about the time when the first cases 
appeared at the university his wife died of typhoid fever. His daugh- 
ter had been ill with the same disease. The oysters which were sold 
to the students had been bedded temporarily in the river at a point 
near the place where a short drain from his house discharges into 
the stream. The water became infected by the flow from the drain, 
and when the oysters were taken up the liquid and other matter 
which accompanies oysters so dislodged, either on the outside of the 
shell or inside of it, contained the germs of typhoid. Cooking killed 
these germs, but the raw oysters carried to those who ate them a 
dose of typhoid poison. It is reported that several recent cases of 
typhoid in New Haven have been traced to infection thus conveyed 
by oysters from the same river." 

It has generally been believed heretofore that typhoid bacilli do 
not develop in salt water, but the circumstantial evidence points 
strongly to their having existed in the brackish water above de- 
scribed, and, according to Foote, of New Haven, the typhoid bacillus 
will live eight days in water from an oyster bed. The oyster juice 
also contains the bacilli, and the bacilli injected into oysters live a 
fortnight in abundance, and are known to have survived for thirty 
days. 

Two fatal cases of typhoid fever have been reported in Berlin 
as due to infection from raw oysters. Sir William Broadbent re- 
ported in the British Medical Journal ten cases which he saw during 
November and December, 1894, and attributed to the same origin. 
A number of cases have been traced in Italy and France to the 
eating of raw oysters. Arthur Newsholme, of Brighton, England, 



390 DISEASES CAUSED BY DIETETIC ERRORS 

studied 181 cases of typhoid fever occurring there from 1893 to 1896, 
of which nearly one third were attributed to eating raw shellfish — 36 
to oysters, and 20 to other varieties. All the shellfish were con- 
taminated by sewage. 

Oysters may also give rise to severe enteritis, and possibly chol- 
era when derived from infected sewage beds. Frankland, however, 
has determined that cholera bacilli injected into oysters do not sur- 
vive more than twenty-four hours. 

It is possible, although it is not definitely proved, that typhoid 
bacilli may be conveyed upon raw vegetables and fruits which have 
been washed in contaminated water. It is known that cholera germs 
are conveyed in all of these ways. From this reason, as well as 
from the necessity of avoiding diarrhoea, it is customary to advise 
against the use of all raw fruits and vegetables during the preva- 
lence of a cholera epidemic. 

DIPHTHERIA AND SCARLATINA 

Diphtheria germs, and even those of scarlatina, can be conveyed 
in milk should they have access to it. Several epidemics of both 
diseases have been traced among families employing in common a 
milkman whose children at home had one or other disease. In Buf- 
falo, N. Y., in 1899, an epidemic of 29 cases of scarlatina was defi- 
nitely traced to consumption of milk delivered by one milkman, who 
obtained the supply from a farmer who had the disease at the time 
of milking. 

FOOT-AND-MOUTH DISEASE 

The foot-and-mouth disease may be propagated from the use 
of milk from an infected cow. Sometimes this milk is of a bad 
taste and odour, or it may even be mixed with blood or pus if the 
nipples are excoriated or if the udders are inflamed. In other cases 
the milk appears normal, but when boiled coagulates readily into 
small flocculi in a bluish whey. Such milk is rendered innocuous 
by the process of boiling. Children are more likely to contract the 
disease in this way than are adults, owing to their greater consump- 
tion of cow's milk. 



FOOD INFECTION THROUGH FLIES 

The importance of preventing food infection through the agency 
of common house flies is just beginning to be appreciated. These 
insects are admirably adapted to convey infection from their great 
numbers and incessant activity, as well as their numerous feet, capa- 
cious intestines, their frequent evacuations, and disgusting habits 
of alighting and feeding upon sputum, manure heaps, and all animal 



IDIOSYNCRASIES IN REGARD TO FOOD 39 1 

discharges. When fed on tubercular sputum the bacilli have been 
discovered alive in their intestines, and cholera germs have been 
found adhering to their feet by which they are easily transported 
from a choleraic stool to a piece of bread or a raw fruit or vegetable, 
destined in turn to infect the first person who is unlucky enough to 
eat it. During the cholera epidemic in Hamburg Dr. Simmonds 
found comma bacilli in the intestines of flies in the post-mortem 
room where dead cholera patients were examined. The bacilli re- 
mained one and a half hour in the flies — time enough to be carried 
a long distance or to be widely distributed. When the matter is 
further investigated it will doubtless be shown that other kinds of 
infection are often spread by the medium of these vulgar pests. 
Ordinary pus infection is readily carried by flies. In the hastily con- 
structed camps of our troops in the Spanish-American War, and in 
those of the British soldiers in the Boer War, many cases of typhoid 
fever were traced to infection by flies that had access to the latrines 
in which typhoid stools had been emptied. 

IDIOSYNCRASIES IN REGARD TO FOOD 

Idiosyncrasies are found to exist with some persons in regard to 
special articles of food, and these cannot be readily explained. As 
a rule, if marked, they extend throughout life, but it is not seldom 
the case that some people pass through periods when a particular 
article of food disagrees with them which they have been previously 
able to eat with impunity. Some are unable to digest milk and are 
immediately nauseated or made " bilious " by it, while others cannot 
eat eggs, and yet can drink milk, while some cannot take either. 
Some can eat the white and not the yolk of eggs. Others, again, 
cannot eat fat in any form or are unable to digest some one variety 
of fat, especially hot mutton fat. Some persons acquire a head- 
ache whenever they eat butcher's meat in excess. Among the com- 
moner idiosyncrasies of diet are the revolt of the system which 
occurs from the use of shellfish of all kinds, but especially lobsters, 
and from strawberries. Fothergill reported the case of a lady who 
all her life was unable to drink coffee, of which she was very fond, 
without having diarrhoea from it within an hour or two. Temporary 
or functional visual disturbances may be produced by alcohol and 
by indulgence in " high " game or eating spoiled food. Casey A. 
Wood, of Chicago, has reported a case of recurrent amblyopia in a 
physician of fifty-four years of age, who invariably had an attack 
resulting from the eating of chocolate in any form. 

Food idiosyncrasies are not infrequently hereditary, and may 
affect several members of one family. They are wholly independ- 
ent of ordinary dyspeptic conditions, and may be present in those 
whose digestive organs are exceptionally robust. 
27 



392 DISEASES CAUSED BY DIETETIC ERRORS 



X. Alcohol Poisoning — Alcoholism — Delirium Tremens 

The position of alcohol as both a food and a stimulant has al- 
ready been fully discussed in connection with its physiological and 
dietetic action (p. 228). 



ALCOHOL POISONING 

The effects of poisoning by alcohol differ according as they are 
acute or chronic, and according to the previous alcoholic habits of 
the patients. Habitual drinkers easily consume quantities of raw 
spirits which might prove fatal if drunk by one not inured to their 
use. Men have been known to drop dead a few moments after 
quickly drinking a pint or more of whisky on a wager. Although, 
according to Professor Atwater, two and a half ounces of alcohol 
may be daily oxidised by a person in health, the continued use of 
beverages containing this quantity is liable to produce alcoholism in 
any one. 

When alcohol is used to excess as a stimulant its effects are 
manifested by the increased mental excitement of intoxication. 
There is a period of restlessness, insomnia, loss of memory, and 
irritability. The stage of insensibility and final stupor or coma de- 
velops later after long taking large quantities of alcohol. Patients 
suffering from alcoholic coma are always in danger of heart failure 
from paralysis of that organ, which forms no exception to the gen- 
eral rule that overstimulation of any muscle produces exhaustion 
and paresis. When in this condition, however, they are fortunately 
incapacitated from making any sudden or violent exertion, and in 
acute cases alcohol is eliminated with considerable rapidity from 
the various excretory organs of the body, especially the kidneys, 
in the form of waste matter, which it produces. 

The continued use of strong spirits, as well as the occasional use 
of alcohol in excess, almost invariably results after some time in 
the establishment of chronic gastric catarrh, which is characterised 
by the formation of thick, ropy mucus, and thickening of the gastric 
mucous membrane, with atrophy of the gastric glands. There is 
always malfermentation with more or less acidity and heartburn and 
considerable nausea, especially in the morning, when the mucus or 
products of indigestion have accumulated overnight. There is also 
an increased production of connective tissue in the stomach wall. 
The effects of chronic alcoholism upon the alimentary canal are 
chiefly manifested in the stomach, although the intestine may share 
in the pathological changes. This is due to the fact that the alcohol 
reaches the stomach in a more concentrated form, and that being! 
very diffusible it is absorbed in great part without entering the) 
intestine. 



ALCOHOL POISONING 393 

In addition to the local gastric catarrh and inflammation which 
it may produce, alcohol gradually alters various viscera, causing cir- 
rhosis of the liver, nephritis, chronic endarteritis, etc. Chronic alco- 
holism is one of the commonest causes of multiple neuritis, chronic 
pachymeningitis, and myelitis. 

In chronic alcoholism the intense craving for alcohol in any 
form tends to weaken and overcome the will power and debase the 
moral nature of the individual, and those who are afflicted by this 
habit very often drink periodically — that is, the intervals between 
their excesses may be prolonged for one or several months, during 
which time they touch no alcohol in any form, and, indeed, in some 
cases they may have a positive loathing for it. The very sight of it 
nauseates them. The craving then returns and becomes so irresisti- 
ble that if they cannot obtain liquor they have been known to drink 
raw alcohol from spirit lamps or in any shape in which they can 
obtain it. The craving consists partly of a special appetite for liquor 
in the stomach, and in part of the general irresistible desire of the 
system, which is somew T hat akin in its effect to intense hunger, al- 
though the effect on the will power is more disastrous. 

The evil results of excessive indulgence in alcohol are strikingly 
shown by its effect upon liquor dealers, the mortality among whom, 
from various diseases, as compared with that of other men, bears 
the ratio of 3 to 2. When a similar comparison is made in regard 
to the mortality of liquor dealers from special diseases, the result 
is still more striking; thus for liver diseases the ratio is 6 to 1, for 
nervous diseases nearly 2 to 1, and for alcoholism 5.5 to 1. 

The dietetic causes of inebriety form an interesting study. The 
craving for alcohol is undoubtedly fostered in many cases by monot- 
ony of diet, by ill-prepared food, and the resulting catarrhs of the 
alimentary canal and lack of nutrition. To meet the symptoms of 
anorexia, heartburn, and weakness from malnutrition " tonics " and 
" bitters " containing alcohol are often resorted to, or alcohol is 
taken more directly in the form of strong spirits. While this may 
temporarily relieve the craving for some form of stimulation, it often 
merely makes the digestive disturbance worse and increases the 
mental depression of " biliousness." In such manner the drink habit 
is easily established. 

Dietetic Treatment of Mild Cases. — In the milder cases charac- 
terised by nervousness, muscular tremors, indigestion, dyspepsia, 
a foul breath, coated tongue, and urine loaded with urates or crys- 
talline deposits, if the patient can be induced to stop all alcoholic 
drink and take abundant water or alkaline effervescing waters 
(Vichy, Seltzer, Apollinaris, etc.), together with a proper diet, 
much can be done to ward off an acute attack. A very good 
example of the appropriate diet is the following from Foods and 
Dietaries : 



394 DISEASES CAUSED BY DIETETIC ERRORS 

" Breakfast. — A lightly boiled egg, or a little bit of whitefish or 
of bacon, or a light savoury omelet ; toast, or bread and butter ; a 
cup of weak tea or of coffee and milk. 

" Early Dinner, I o'clock. — A slice of roast mutton, or the wing 
of a chicken, or a plain cutlet, with a spoonful of mashed potato 
and some well-boiled green vegetable. A few spoonfuls of any plain 
milk or bread pudding, with occasionally some stewed fruit. Bever- 
age. — A glass of plain or aerated water, to be taken slowly towards 
the close of the meal. 

" Afternoon. — A cup of tea with milk may be allowed, with toast 
or rusk. 

" Supper, 7.30. — A light meal of fresh fish, or of bird, or of calf's 
head, or of tripe, with dry boiled rice or bread. Beverage. — Small 
glass of milk and soda water." 

In cases of periodic alcoholism, in which the patient has no crav- 
ing for drink between his attacks, it is best to recommend for the 
intervals a non-stimulating diet, avoiding condiments and richly 
cooked or highly seasoned food of all sorts. Fruits, plainly cooked 
cereals, and vegetables should constitute the staple diet, and animal 
food should be eaten only in moderation. 

In some of these cases overindulgence in food excites the crav- 
ing for alcohol. 

Dietetic Treatment of Severe Cases. — The treatment of the severer 
cases, in which dyspeptic or gastro-intestinal symptoms predominate, 
but in which delirium tremens is not necessarily present, is mainly 
that of gastric catarrh, described elsewhere. It must be adapted 
to the degree of inflammatory or cirrhotic changes which have al- 
ready taken place in the different organs. The patients usually feel 
much worse in the mornings, having nausea and vomiting or 
loathing for food, but later in the day they may recover con- 
siderable appetite and power of digestion. Advantage should 
be taken of this fact in feeding them. The following menu from 
Foods and Dietaries is very well adapted to this stage of chronic 
alcoholism : 

" Breakfast, say 8 o'clock. — A cup of weak tea with an egg beaten 
up in it, and a slice of toast. 

" Second Meal, 10.30. — A cupful of good meat soup, thickened, 
or a cup of peptonised milk, warmed, with toast or rusk. 

" Early Dinner, 1 o'clock. — A tablespoonful of pounded meat on 
toast, or a small teacupful of fresh meat juice, with fingers of toast. 
A couple of spoonfuls of sago, custard, or tapioca pudding. Bever- 
age. — Half a tumblerful of milk and soda water (equal parts). 

" Afternoon Tea, 4.30. — A cup of weak tea or of cocoa nibs, with 
rusk or a plain biscuit. 

" Evening Meal, 7 o'clock. — A cup of soup or of mutton broth, as 
at the forenoon meal. 



DELIRIUM TREMENS 395 

" 9-3° or I0 - — A cup of peptonised milk and a slice of thin bread 
and butter. 

" Food During the Night. — In case of wakefulness there should be 
within reach, and arranged so as to be readily warmed, peptonised 
milk.'' 

DELIRIUM TREMENS 

Delirium tremens is a condition of active maniacal excitement 
which in its worst form is accompanied by intense general nervous 
excitement, muscular weakness, and hallucinations, chiefly of sight 
and hearing, of a terrifying or disgusting nature. 

Delirium tremens is sometimes excited by a temporary debauch, 
but as a rule this results in a condition of coma rather than mani- 
acal excitement. Delirium tremens is much more characteristic of 
chronic than of acute alcoholism. 

In the earlier stages the heart action may be apparently vigor- 
ous and the pulse full and bounding, but the heart may become sud- 
denly exhausted and cardiac failure is the chief danger. 

Dietetic Treatment. — The indications for dietetic treatment are 
to make sure that the alimentary canal, which has been previously 
disordered and congested, if not inflamed by the excessive irritation 
of strong alcoholic drink, is emptied of any accumulation of abnor- 
mally fermenting food. In the earlier stages brisk purgation or an 
evacuant enema should be given. If the stomach is overloaded with 
improper food, free vomiting should be produced by ipecac or apo- 
morphine, provided the condition of the patient is sufficiently vigor- 
ous to warrant this procedure. Large draughts of water, aerated 
and saline waters, should be taken to promote the activity of the 
kidneys and to dilute the poison in the system. The alimentary canal 
having thus been emptied of fermentation products, it becomes nec- 
essary to support the patient's strength with abundant nourishment. 
The appetite for food is usually entirely absent, being replaced by 
that for drink, but the patient must be urged to take all the nourish- 
ment possible, and to this end it may be given in fluid form in small 
frequent doses. The food should be stimulating and predigested. 
If there is much gastro-intestinal irritation, pancreatinised milk, 
strong meat soups, beef tea with dropped eggs added to it, and egg- 
albumin may all be given. The mucous surface of the stomach has 
been long accustomed to the stimulating effect of strong alcohol, 
and if this be suddenly and completely removed, gastric discomfort 
and craving for drink become intolerable. This condition is often 
relieved by using strong spices or condiments, such as ginger or 
Cayenne pepper, in quantities which would be injurious to a normal 
stomach, and might possibly produce gastritis. These substances 
may be added to food and non-alcoholic drink, although the stomach 
may be actually inflamed. Experience proves that highly seasoned 



396 DISEASES CAUSED BY DIETETIC ERRORS 

food is sometimes borne with the effect of diminishing the suffering 
of the patient. This applies, of course, only to very robust cases, 
in which an otherwise vigorous constitution has been abused by 
excessive indulgence in drink, and the gastric stimulant should not 
be long continued. In this variety of cases the quantity of food 
which the patient is encouraged to take need only be limited by the 
ability to digest it, for the digestive organs can be kept fairly active 
without being overloaded to the extent of exciting abnormal fer- 
mentation. The nervous system is always strengthened and soothed 
by abundant nourishment. 

Ginger ale constitutes a very serviceable non-alcoholic beverage, 
which in part relieves the craving for stronger drink. It may be 
drunk in considerable quantity, and it possesses the advantage of 
being somewhat laxative, diuretic, and mildly stimulating to the 
stomach. Care should be taken to obtain a pure article, as there is 
much inferior ale in market. 

It is well known that persons who for many years have indulged 
excessively in spirituous drinks are very apt to develop delirium 
tremens if taken suddenly ill, or if they sustain an injury such as a 
fracture, although they may have drunk no liquor for many weeks. 
In such cases the patient's life is in serious danger and it may be 
necessary to give more alcohol to maintain the accustomed influence. 
The conditions here to be met are very different from those resulting 
from an ordinary debauch, when liquor should be entirely withheld. 



PART VII 
ADMINISTRATION OF FOOD FOR THE SICK 



METHODS OF FEEDING THE SICK 

General Rules 

In no branch of her work can the nurse be of more service than 
in her ability to feed a very sick patient properly. There are many 
details which can only be mastered by extensive bedside experience 
and close observation, and so much depends upon tact and discretion, 
which can never be learned from text-books or lectures, that it is im- 
possible to formulate rules for feeding which shall cover all cases ; 
but the following suggestions will be found applicable in many in- 
stances. 

Miss Nightingale wrote that " to watch for the opinions which 
the patient's stomach gives, rather than to read ' analyses of foods,' 
is the business of all those who have to settle what the patient is to 
eat — perhaps the most important thing to be provided for him after 
the air he is to breathe." 

The Appetite. — In judging of the patient's appetite it must be 
remembered that what is supposed to be a lack of desire for food is 
possibly due merely to defective cooking, to serving meals at inop- 
portune moments, or to selecting food which is not to his liking. 
There may be appetite enough for food, but not for the particular 
food offered, and it is the province of the nurse to differentiate such 
matters. She should not only save the patient from physical exer- 
tion, but from the effort of thinking as well. 

It is the function of the nurse to observe and record all the con- 
ditions of the patient's appetite, digestion, and likes and dislikes for 
different foods, and when her instructions have not been specific, or 
have not provided for emergencies, she should make it a point to 
have them understood at the next visit of the physician. A thorough 
practical knowledge of dietetics should be the foundation of the 
nurse's education, and this subject should receive much more atten- 
tion in the curriculum of training schools than is at present bestowed. 

The nurse has a far better opportunity than the physician to 
judge of the patient's appetite and study his whims and fancies in 
regard to food, and she should not fail to report them and under- 

397 



398 ADMINISTRATION OF FOOD FOR THE SICK 

stand very positively from the physician in charge to what extent 
she is to be permitted to humour them and substitute one form of 
food or drink for another. Directions are apt to be given too in- 
definitely to the nurse, and with the best intentions, from lack of 
instruction, she may neutralise the effects of medicines by overfeed- 
ing, or by irregularities in feeding which disorder digestion and in- 
terfere with the action of the drugs, besides making the patient 
worse. She is often merely told to give " soft diet " or " fluid food," 
and she promptly resorts to milk and eggs, which may or may not 
agree and nourish. Or instead of such vague orders she may be 
directed to give only some one form of food, which she conscien- 
tiously does, offering it in spite of the patient's accumulating nausea 
and disgust, with the result of half starving him, because the physi- 
cian has forgotten to allow the nurse any latitude or discretion. 

Regularity in Feeding. — The hospital nurse should be taught 
that it is as important to give food as medicines at regularly appointed 
intervals. Punctuality should be carefully observed in serving all 
meals to the sick. There is much unconscious habit in regard to 
eating, and an appetite which was ready at the accustomed hour of 
receiving food may vanish if the meal is delayed. It is well, when 
possible, to bathe the patient's face and hands before offering a 
meal. It is best always for the same nurse to have the charge of 
feeding a definite number of hospital patients. If they are served 
by a different nurse at each meal it is much more difficult to report 
those whose appetites are defective or capricious. 

Quantity of Food. — Among the first considerations is the proper 
quantity of food to offer the sick, and the extent of its dilution. 
Miss Nightingale has said that " an almost universal error among 
nurses is the bulk of the food, and especially of the drinks, they offer 
to their patients," and " it requires very nice observation and care 
(and meets with hardly any) to determine what will not be too thick 
or strong for the patient to take, while giving him no more than the 
bulk that he is able to swallow." 

By diluting milk, stimulants, and gruels too much, or making 
beef tea too weak, the quantity of the fluid is so great that the patient 
soon tires of swallowing, and stops before enough nourishment has 
been obtained. Predigested milk possesses the decided advantage 
that it aids the assimilation of the milk without adding to its bulk, 
as lime water and other substances do. 

When the appetite flags it is unwise to ask the patient each time 
beforehand what he would like to eat. It is often the unexpected 
which pleases. The smell of cooking and the noise of the prepara- 
tion of food should be kept from the sick-room. The nurse should 
never eat her own meals in the presence of the patient. 

Details of serving Food. — Hot food should be served very hot 
and cold articles very cold, for lukewarm food is unpalatable. In 



METHODS OF FEEDING THE SICK 399 

serving hot beverages or foods the cups or plates should be first 
well heated. Milk and butter should be kept cold and well covered. 
A simple refrigerator is easily improvised by placing a few large 
lumps of ice in a dish pan or pail kept by an open shaded window, 
and wrapping them in flannel to prevent evaporation. 

Patients may appear too ill to notice details, whereas they are 
often only too ill to speak of them, and a refined, fastidious, or nerv- 
ous patient may have the appetite wholly destroyed by the careless- 
ness of a nurse who tastes the food in the. patient's presence or with 
his spoon, or who serves food with unclean hands. Untasted food, 
dishes after use, or half-emptied cups or glasses should never be 
left standing about the sick-room. Nothing is more uninviting than 
to have to drink from a glass to the sides of which stale milk is 
adhering. If there is any suspicion of the absolute freshness of 
milk, eggs, butter, or fish, they should never be served. 

It is equally important to make all food look inviting by offering 
it with the most attractive china which the house affords, and with 
only the cleanest of linen. Dishes should always be wiped dry on 
the outside, and pains should be exercised not to spill the contents 
of cups into their saucers. 

These may appear trivial details, but it must be remembered that 
the horizon of the sick-room is very limited, and a patient who has 
been long confined to bed with a serious illness thinks a great deal 
of his immediate surroundings. The taking of food is the chief event 
of the day for him, and too much care cannot be bestowed upon the 
minutiae of service, while the natural stimulants to appetite — such 
as fresh air, exercise, and enlivening companionship — are necessarily 
wanting. 

When patients are able to partially sit up for their meals, the 
nurse should see that they have a comfortable position in the bed, 
and that the food tray does not cramp the arms or legs. The effort 
of sitting up may cause fatigue too soon and destroy the appetite 
before the meal is half done. 

As a rule, twice-cooked food should not be served to invalids. 
This applies especially to meat, fish, and vegetables. Whenever 
economy is an important consideration, it is better to cook but little 
food at a time, and serve it fresh and hot. Food is often made un- 
palatable by being too greasy, and this is one of the chief objections 
to the use of meat broths, and mutton or chicken broth should 
always be several times skimmed before they are given, and blotting 
paper or a bit of bread can be passed over the surface to remove 
the last trace of oily substance. A chafing dish is invaluable for the 
convalescent from protracted illness. 

When the dietary ordered' is very limited in variety, the patient is 
often gratified by having his food served in " courses," and will eat 
more than if given everything at once. 



400 ADMINISTRATION OF FOOD FOR THE SICK 

In other cases, when a patient is first allowed to sit up for half 
an hour or more beside the bed, it may be well to utilise this time 
for giving the principal meal of the day, which will be eaten with 
more relish, and perhaps better digested in consequence. 

Patients having nausea or other gastric disorder or diarrhoea 
should be given but little food at once. Small, oft-repeated feed- 
ings are best for them. As a rule, invalids need more salt as a condi- 
ment, but less sugar, than those in health. 

When patients are being fed with fluids, wholly different recep- 
tacles should be used for holding their medicines, or the association 
of ideas may be strong enough to destroy what little appetite there 
is, and even to produce nausea. 

The nurse should always have a cheerful manner and a cleanly 
and tidy appearance, which contribute much towards the patient's 
appetite. She should never offer nourishment too soon after re- 
moving the vessels employed for the patient's discharges or evacu- 
ations, but should allow a proper interval to elapse, and let it be 
evident that she has thoroughly cleansed her hands. No form of 
perfumery should ever be used by the nurse. Bread crumbs should 
never be allowed to fall into the bed, especially of a helpless patient. 

When possible, it is well to divert the patient's mind from his 
ailments while feeding him by introducing some cheerful or inter- 
esting topic. 

Feeding Helpless Patients. — In feeding helpless patients with 
fluids, if the head is to be raised, it should be done by placing the 
hand beneath the pillow and lifting it gently. This affords much 
better support, and is more comfortable for the patient, for the head 
is less likely to be bent so far forward as to interfere with swallowing. 
If a tumbler is used, it should always be small and not more than 
two thirds filled. An average breakfast-cup holds eight fluid ounces, 
and an average tea-cup six fluid ounces. A thirsty patient derives 
more satisfaction from draining a small glass than from sipping from 
a large one which he is not allowed to empty. The feeble patient 
should not be allowed to swallow during inspiration, and the nurse 
should be careful that each mouthful is swallowed before another is 
given, to prevent serious coughing. 

When a glass tube is used for feeding, it should have a flattened 
end to hold in the mouth, and should be bent near the centre at a 
slight angle, so that it is unnecessary to flex the patient's head. If 
feeding-cups with spouts are employed, they should be of glass, so 
that the nurse can see how much the patient is taking; otherwise 
fluid is apt to be poured into the mouth in too large a quantity. As 
a rule, the bent tube is decidedly better to use when the patient has 
any power of suction at all. Even when he has not, the glass may be 
raised by the nurse, so that the fluid flows into the mouth without 
effort. The cup and tube should always be prevented from dripping. 



METHODS OF FEEDING THE SICK 401 

Sleep and Feeding. — Patients need only be aroused from sleep 
to take nourishment in serious cases. Usually the ease with which 
a patient drops asleep should determine the necessity for awakening 
him. Sleep is often more beneficial even than food, but there are 
cases in which a patient awakens to take a sip of milk or a few 
mouthfuls of food, and will immediately drop off to sleep again. 
Such patients may be aroused for food every two hours if there is 
need, as there may be in typhoid fever. Some patients are annoyed 
by awakening at three or four o'clock in the morning, not being able 
to sleep again. Food of some sort should always be kept on hand 
during the night, and drinking a cup of hot bouillon or cocoa will 
often enable them to fall asleep again for two or three hours. 

Cleansing the Mouth. — The patient's comfort is very dependent 
upon keeping a clean mouth, as indeed are his appetite and taste. 
A helpless patient whose mouth and lips are allowed to become 
parched and sour will refuse nourishment which he might otherwise 
gladly take. The mouth should be rinsed each time after eating 
with pure water, hydrogen peroxid, or diluted Listerine (two tea- 
spoonfuls to the tumbler of water), or borax water of similar strength. 
It is much easier to keep the mouth clean in this manner than to 
disinfect it after it has been neglected. Milk especially lingers on 
the mucous surface, and, fermenting there, destroys the sense of 
taste and develops germs that interfere with digestion. When the 
patient cannot rinse his own mouth, it must be frequently cleansed 
by the nurse with a swab of fresh cotton fastened on a small flexible 
stick, such as a piece of splint, and moistened with the mouth wash. 
The best tongue scraper is made with a piece of whalebone, about 
nine inches long, bent into a loop. If this be applied before the 
patient's meals, the taste nerves of the tongue will be uncovered from 
the accumulated debris which coats them, and the appetite will be 
improved. Dry lips should be moistened with vaseline or cold 
cream, not glycerin. 

Cracked ice will keep much longer if not allowed to float in melt- 
ing water. The contact of a metal spoon or dish also melts it sooner, 
by virtue of the great conductivity of metal. 

A piece of cheese cloth, mosquito netting, or linen may be tied 
over a cup by an elastic band, and the fragments of ice split off with 
a pin may be laid upon the cloth, so that the melted fluid drains away 
beneath. 

Disinfection of Utensils. — All dishes or utensils used in serving 
food to patients having syphilis, stomatitis, or diphtheria, or any 
infectious disease likely to be communicated through such means, 
should be boiled for at least an hour in water containing a few 
teaspoonfuls of soda. Syphilitic patients, especially, should have 
their own set of food receptacles, spoons, forks, etc., properly la- 
belled, to prevent any one else from using them. 



402 



ADMINISTRATION OF FOOD FOR THE SICK 



Feeding Unconscious Patients. — The feeding of unconscious pa- 
tients demands special care and skill. They should never be given 
anything but fluid nourishment, and this must be fed with a spoon or 
through a catheter. Sometimes, if the jaw is set, a medicine dropper 
may be utilised. Not over a teaspoonful should be given at once, 
and the nurse must make sure that it is swallowed before she repeats 
the experiment. It should be remembered that the mechanism of 
deglutition is not excited by one or two drops of fluid, but usually 
at least half a drachm is required to start this reflex. In feeding 
comatose infants or children with tubercular meningitis, apoplexy, 
etc., fluid may be poured into the nostril with a spoon rather than 
into the mouth. It disturbs the child less than does the effort to 
force open the mouth, and if the head is lying back the fluid trickles 
down the posterior pharyngeal wall. Any excess of fluid is re- 
turned through the other nostril. There is no greater danger of 
choking when fed by this method than by the mouth. It is usually 
better, however, to use a soft catheter with a funnel attached to 
the free end. The catheter is oiled or dipped in vaseline or butter, 
and passed gently through the nostril down into the oesophagus, 
or, if desired, into the stomach. Before pouring any fluid into it 
through the funnel it must be made certain that the patient is breath- 
ing easily, and that the tube has not made a false passage into the 
larynx. Such an accident is very rare. This topic will receive fur- 
ther attention in connection with Lavage. 

Gavage, or feeding with the stomach tube, is described under that 
heading. Xasal feeding is employed sometimes for gavage in young 
infants, in feeding children with diphtheria, or the insane, who may 
refuse food or resist the passage of a tube through the mouth by 
biting, and it may be used when the mouth is sore from ulceration 
or the effect of corrosive poisons. 

When patients are living upon " teacup diet," or broths and 
gruels, it is a common mistake to give them a diet which is either 
too low in carbohydrates or deficient in protein. The proper pro- 
portions to be prescribed, unless there is some special indication for 
the contrary, will be appreciated by a comparison of the following 
table, compiled by Mrs. E. H. Richards, and those previously given 
on p. 287. 

A Common Invalid Ration too Low in Cai-bohydrates (Mrs. Richards) 



1 pint of beef juice, containing 7 per cent.. . . 
1 pint of whole milk 

1 quart of flour gruel made with whole milk. 

2 quarts of liquid. Total 



Protein. 



66.7 



Fat. 



Grammes. 


Grammes. 


3i-5 




17.0 


18.O 


18.2 


18.2 



Carbo- 
hydrates. 



36.2 



Grammes. 

22 

38 



60 



Calories. 



129.O 
325-5 
397-9 



852.4 



METHODS OF FEEDING THE SICK 403 



Nutrient Enemata 

Rectal Absorption. — That all mucous membranes are capable of 
absorbing* certain materials from their surfaces and passing them 
into the blood vessels or lymphatics has long been recognised ; but 
it is only of comparatively recent years that this knowledge has been 
applied extensively to the purpose of nourishing patients by means 
of the rectum, and the fact is now established that sufficient aliment 
may be absorbed from the mucous membrane of the rectum or 
sigmoid flexure alone to sustain life for a considerable period, 
amounting in some cases to from four to seven weeks. Moreover, 
the rectum may be utilised for accessory feeding for many cases in 
which the stomach is able to digest some food, but not in sufficient 
quantity to prevent emaciation. 

Whenever rectal food enemata are employed certain principles 
should be observed : 

1. The rectal surface must be cleansed from all mucus and faeces. 

2. The irritation of the rectum should be allayed as far as pos- 
sible. 

3. The quantity and quality of food thus administered should be 
so regulated as to avoid exciting peristalsis, and yet allow of the 
complete absorption of one injection before another is given. 

The minutest details which will secure the best conditions for 
absorption should never be regarded as too insignificant. Some 
patients find the idea of rectal feeding very repulsive, and dislike to 
submit to it ; but with a little tact and perseverance their objections 
can usually be overcome. 



CONDITIONS NECESSITATING RECTAL FEEDING 

The conditions which may require the use of rectal feeding are 
these : 

I. Temporary obstruction to the entrance of food into the ali- 
mentary canal. Rectal feeding must be resorted to until the ob- 
struction — such as the presence of new growths and foreign bodies, 
or inflammatory conditions with swelling in the mouth, pharynx, or 
oesophagus — can be overcome. 

II. Inability to swallow food from coma, delirium, or paralysis 
affecting the mechanism of deglutition, as, for example, post-diph- 
theritic paralysis. 

III. Extreme irritability, pain, acute inflammation or ulceration 
of the upper portion of the alimentary canal, such as that excited by 
corrosive poisons like carbolic acid, ammonia, etc. 

IV. Stricture occurring in any part of the alimentary canal above 
the rectum. 



404 ADMINISTRATION OF FOOD FOR THE SICK 

A'. Prolonged reflex vomiting, such as may occur in pregnancy 
and seasickness. 

VI. Gastric ulcer, for the purpose of resting the ulcerated surface 
and allowing it to heal. 

VII. Cancer of the stomach with inability to absorb or digest 
sufficient food, especially with obstruction to either the cardiac or 
pyloric end of the organ. 

VIII. Any form of severe gastric irritation, such as occurs in 
acute gastritis. 

IX. Exhausted conditions of the system which may be present 
during the course of severe fevers in which absorption of even pre- 
digested food is largely suspended. 

X. For the insane who refuse food by the mouth. 

XL To supplement the action of a feeble stomach, or when for 
any reason, such as total lack of appetite, emaciation is rapidly pro- 
gressive. 

Hunger and Thirst during Rectal Feeding. — These symptoms are 
not necessarily present after the first day or two of rectal feeding. 
In an obstinate case of gastric haemorrhage in which absolutely 
nothing — not even water — was given by the mouth for more than 
a week, I questioned the patient in regard to her sensations of 
hunger and thirst, and she told me that they were entirely relieved, 
after the first twenty-four hours' use of nutrient enemata. The 
mouth and tongue were not dry, and she did not lose weight during 
this period. I have been told the same thing by other patients. 

An interesting case was reported by C. W. Brown, of Washing- 
ton, in which a patient suffering from carcinoma with ulceration of 
the pyloric end of the stomach was supported for forty-three days 
upon exclusive rectal nourishment consisting of from four to six 
ounces of beef tea and milk, which were given on an average once in 
three hours, with the occasional addition of laudanum and a little 
whisky. During an interval of improvement which followed the 
exclusive use of injections, the patient was able to take some food 
by the stomach, though not enough to satisfy the craving of hun- 
ger and prevent a feeling of faintness ; but these symptoms were 
overcome by giving four nutrient injections daily in addition to the 
milk taken by the stomach. 

Method of Injection. — The common practice of giving nutrient, 
enemata by a Davidson syringe with a short hard-rubber or steel 
nozzle is always to be condemned. In the hands of an unskilful 
nurse, irritation and sometimes haemorrhages are likely to be pro- 
duced in this way, sooner or later. 

In commencing the use of rectal alimentation, especially in cases 
which manifest much irritation of the lower bowel, it is important 
to employ a long, soft, flexible rubber catheter or rectal tube which 
can be passed well up, for eight inches or more, to the sigmoid 



METHODS OF FEEDING THE SICK 405. 

flexure. In selecting the tube, one should be chosen which is not 
so flexible that it is liable to bend or double upon itself, but which 
is not so stiff as to give pain or damage the mucous membrane if 
it happens to catch in a fold of its surface. For children a No. 12 
or No. 14 ordinary " velvet-eyed " flexible catheter may be used, 
and passed up as high as the sigmoid flexure. For adults the tube 
should be of moderate calibre, not exceeding the diameter of a 
stout pen handle. The tube or catheter should be dipped in sweet 
oil, melted butter, or vaseline ; but glycerin must not be used, for 
it excites peristalsis. 

In adults the tube should be passed in for from ten to twelve 
inches, for the injection should be placed as high up as possible. 
When this is done there is less liability to its rejection, and it is 
brought in contact with an extensive mucous surface. There is a 
further physiological or anatomical reason for placing the injection, 
as high up as may be, in the fact that the sigmoid veins and those 
returning the blood from the upper rectum communicate with the 
inferior mesenteric vein, while those from the lower third of the 
rectum communicate with the inferior vena cava. Consequently, 
whatever is absorbed by the wall of the inferior third of the rectum 
passes into the inferior vena cava without going to the liver, but 
that which is absorbed higher up is returned to veins whose contents 
reach the liver directly through branches of the vena porta. It is 
in the liver that the further assimilation of protein takes place in 
great part, and hence the desirability of observing this rule. 

It was found by Brown, in the case above cited (p. 404). that 
the patient was able to discriminate between the taste of iodide of 
potassium and ergot, etc., in from a quarter to half an hour after 
these medicines had been given per rectum. The same phenomenon 
has been noticed from the injection of such substances directly into 
the stomach through a gastric fistula, and it is due to their ready 
absorption and conveyance in the blood to the taste bulbs in the 
tongue or to the saliva, in which fluid the iodide of potassium is 
promptly excreted. 

According to some observers, under the best conditions not over 
one fourth of the necessary nutriment can be absorbed from the 
rectum (Bauer). Such a statement should be considerably modified, 
for, as a matter of practical experience, many patients may be kept 
alive and gain slightly in weight upon the use of nutrient enemata, 
when they are intelligently given. If injected but a short distance 
into the intestine, the absorbing surface is so limited that compara- 
tively little material is taken up ; but if given in the manner pre- 
scribed above, through a long catheter inserted high up, much more 
will be retained, and the benefit derived from such injections will 
be enhanced. 

The injection should be applied by means of a small hard-rub- 



406 ADMINISTRATION OF FOOD FOR THE SICK 

ber syringe, which need not hold over two ounces. Very little force 
should be used, and the patient must be told not to strain. After 
the syringe is filled, by holding it vertically nozzle uppermost and 
pressing it until the fluid exudes from the nozzle, all air is excluded. 
When a Davidson syringe is used for the purpose of injecting small 
quantities of fluid, it very often happens that air is drawn into the 
syringe in addition to the materials of the enema, which, when in- 
jected, is very apt to excite peristalsis and evacuate the bowel. The 
use in unskilful hands of a funnel or fountain syringe for filling the 
tube is open to the same objection — that air is likely to enter the 
rectum. In any case it is well to fill the tube with the injection fluid 
before it is inserted. 

When the enemata are given in gynaecological or obstetric cases, 
it should be remembered that tight tamponing of the vagina may 
interfere with absorption from the rectum. 

Aids to Retention. — Upon withdrawing the tube, if there is danger 
that the injection will not be retained, a soft compress or folded 
towel should be pressed up firmly against the anus for twenty min- 
utes or half an hour. 

The retention of the enema is aided by placing the patient in a 
proper position. He should lie, if possible, upon the left side, with 
the hips raised high upon a pillow, and the injection should be given 
very slowly and carefully. The " Sims " gynaecological position is 
the best, but with the hips more elevated. 

Temperature of Injections. — All food enemata should be given 
moderately warm, at a temperature of 90 or 95 F. They are less 
likely to excite peristalsis than if administered very hot or very cold. 

Number of Injections. — The question of how many injections can 
be given must depend upon the irritability of the rectum. It can 
never be used like the stomach, and it is advisable to begin by order- 
ing an enema only once in six hours. If the rectum is in good 
condition the number may be increased to one every four, or even 
every three hours. In exceptional cases or for emergencies small 
injections, not exceeding one and a half ounce, may be given once 
in two hours ; but if repeated at such brief intervals, they are almost 
certain to excite irritation. 



CARE OF THE RECTUM 

When it is important that nutrient enemata should be continued 
for some time, the exact condition of the rectum should be ascer- 
tained by the physician, and the most minute directions should be 
given to the nurse. The matter is not infrequently left to an attend- 
ant, who is wholly ignorant of the proper conditions to be observed, 
and failure is sometimes reported when a little intelligent attention 
bestowed upon details would overcome all difficulties. 



METHODS OF FEEDING THE SICK 407 

As already stated, many cases have been recorded in which pa- 
tients have been nourished exclusively by nutrient enemata for sev- 
eral weeks, and it is an important fact that the rectum may acquire 
a certain degree of toleration for them. For the first few days they 
may be rejected, but when correctly prepared and administered they 
will soon be successfully retained. But it is only in the most favour- 
able cases that rectal alimentation can be long continued without 
eventually producing irritation and mucous diarrhoea, and in the 
majority of instances this is likely to occur after two or three weeks. 
The enemata must then be discontinued, but may, if necessary, be 
resumed again after a brief interval. Queirolo, of the University of 
Pisa, has fed typhoid-fever patients exclusively by nutrient enemata 
four times a day with success, his idea being to avoid putting any- 
thing into the small intestine capable of fermenting or producing 
toxins, but this practice is not in accord with modern views of the 
disease. 

The presence of haemorrhoids is a serious drawback when the use 
of rectal feeding becomes imperative, and care should be exercised 
not to irritate or inflame them by the passage of the catheter or 
nozzle of the syringe. In such cases it is necessary to use only a 
very soft and flexible catheter, and to allay irritation by the topical 
application of a 2-per-cent solution of cocaine. 

Whenever nutrient enemata are employed for a long time the 
rectum should be thoroughly evacuated and cleansed, at least once 
a day, by flushing with a copious injection of warm soapsuds and 
water, amounting to two or three pints, immediately after which a 
food enema should be given. 

The cleansing enemata may be given through a double or single 
catheter. If a double catheter is preferred, a larger quantity, two 
or three quarts, of water may be advantageously given, and a few 
grains of common salt should be added to each injection. If the 
rectum is irritable, and much mucus coats its inner surface, it may 
be well to add boric acid to the water in saturated solution. The in- 
jection washes out any particles of waste matter or remains of a 
previous nutrient injection, cleanses the mucous surface, stimulates 
its circulation, and prepares it for better absorption. 

Opium in Enemata. — Opium, while it prevents peristaltic action 
and favours retention of the enema, may also tend to interfere with 
its absorption. It is consequently to be avoided, if possible, but 
when irritation of the rectum exists it becomes necessary to inject 
a little laudanum. Ordinarily, three to four minims is sufficient, but 
ten, or even twenty, may be required in some cases. This dosage 
must not be often repeated. Its effect, of course, should be watched, 
and it must not be given too freely. If nutrient enemata are con- 
stantly employed it is sometimes found that a larger dose injected 
by a small hard-rubber syringe half an hour or an hour before giving 
28 



408 ADMINISTRATION OF FOOD FOR THE SICK 

an enema allays the irritation more completely than if the opium 
is given in one of its constituents. Injected by itself, the quantity 
of opium is so small that it is not ejected, but is absorbed, 
and its local action is obtained before the larger bulk of fluid 
in the enema is injected. In other cases it is sufficient to give the 
laudanum in very small quantity, five or six minims with each enema. 
Instead of laudanum, the deodorised tincture of opium or McMunn's 
elixir may be used. 

SUBSTANCES AVAILABLE FOR RECTAL FEEDING 

Of the different classes of food stuffs, there are some which are 
absorbed readily by the rectum, while others are scarcely taken up 
at all. To the latter class belong starches and most of the fats. 
Those starches which are predigested and partially converted into 
sugar may be absorbed to a very limited extent, but not sufficiently 
to add to the nutrition of the body. Maltine may sometimes be 
absorbed. Fats and oils not only remain unabsorbed by the rectum, 
but they prevent the absorption of other foods by coating either the 
mucous membrane or the food itself, and are therefore worse than 
useless. Attempts have been made to give them saponified or finely 
emulsified, prepared with pancreatin or otherwise, but it is doubtful 
if even under these circumstances enough of any form of fat or oil 
can be taken up to be of practical benefit in rectal feeding. 

It is exceedingly important to use only materials which will be 
as completely absorbed as possible. Anything else acts as a foreign 
body, and in time proves more or less irritating. Moreover, it is 
found that many albuminous materials which are absorbed from the 
surface of this portion of the intestine become irritating if given in 
too concentrated a form, such as pure peptone, and they must be 
diluted to two or three times their volume with water or some bland 
fluid. Some forms of albumin are undoubtedly absorbed from the 
mucous membrane of the rectum without predigestion, such as that 
expressed from chopped meat or egg albumin, but it is much better 
to at least partially pancreatinise it. 

Pancreatinised Meat. — In preparing proteid food for absorption 
one of the forms of pancreatic extract or pancreatin may be used. 
Extracts of pancreas are open to the objection that they do not 
keep very long, and unless perfectly fresh they are apt to prove irri- 
tating, and glycerin extracts cannot be used in any quantity on ac- 
count of the aperient action of the glycerin itself. To overcome 
these difficulties, Leube suggests using the fresh pancreas, which is 
to be added in the proportion of one part to three of beef. Both 
the meat and the pancreatic gland should be scraped or thoroughly 
minced and rubbed into a paste with a little warm water. Any fat 
should be carefully removed. The pulp thus obtained is to be in- 



METHODS OF FEEDING THE SICK 409 

jected by means of a suitable syringe with a rather wide nozzle. The 
idea of using this combination is that the digestion, which is begun 
outside, is continued within the rectum, and the products are gradu- 
ally absorbed. Leube claims that this form of nutrient enema may 
be retained for ten or twelve hours, and that it is very rarely irri- 
tating. He sometimes adds egg albumin and even fat to the mixture. 

It has been advised to inject hydrochloric acid into the rectum 
with beef solutions as well as with milk, but this process is too 
irritating, and all artificial digestion should be completed outside of 
the body. Sansom gives the following formula for a meat peptone 
enema for an infant or young child : Shred raw beef or mutton in 
bulk about two tablespoonfuls, add an equal bulk of water, and let 
stand for an hour; then add gradually four tablespoonfuls of milk, 
heated to boiling. When all is well mixed the temperature of the 
mixture will be about 140 F., then add a teaspoonful of Savory & 
Moore's or Benger's liquor pancreaticus, and a pinch of bicarbonate 
of soda. Let the whole remain for six hours, and heat to boil- 
ing. Strain through muslin and preserve the liquid, which will suffice 
for several enemas. 

Blood. — Dried beef blood has sometimes been used as a rectal 
food, but there is no evidence that it is absorbed. In those cases in 
which I have employed it it has usually caked within the rectum 
and prevented the absorption of other materials. Fresh defibrinated 
blood has also been used for the same purpose — four ounces may be 
given every six hours — but it possesses no advantage over predi- 
gested milk or peptones, and is not to be recommended. 

Milk. — Pancreatinised milk in which the process of predigestion 
has not been carried too far is, on the whole, one of the most satis- 
factory foods which can be used by rectum. It should not be rich 
in cream. 

Eggs. — Egg albumin is also one of the best ingredients of nutri- 
ent enemata. It is absorbed unaltered to some extent through the 
rectal mucous membrane, but it is better that it should always be 
predigested by the use of a peptogenic or pancreatinising powder. 
The whites of two eggs may be added to peptonised milk, or, better, 
to peptone solution or one of the meat extracts. Ewald, who has 
experimented extensively with rectal alimentation, states that un- 
peptonised egg albumin is absorbed as promptly from the rectal 
surface as commercial peptone, while peptonised egg albumin is 
taken up even better. The absorption of the albumin is furthered 
by the addition of a little table salt to the injection — about fifteen 
grains to each egg — but this is sometimes irritating to the rectum. 

The yolk of egg is not recommended for rectal use, for although 
it contains albuminous material, so much fat is mixed with it, which 
is not absorbed excepting by the intestinal villi in the small intestine, 
that it is practically useless. 



410 ADMINISTRATION OF FOOD FOR THE SICK 

Grape sugar is highly diffusible and nutritious. A teaspoonful 
or two may be added to rectal enemata occasionally with advantage. 

Alcohol. — The alcohol used for rectal injection should be in the 
form of good liquor, somewhat diluted. If pure alcohol is given, 
it should be diluted in three or four parts of water, when it becomes 
less irritating to the mucous membrane and is more easily absorbed. 
Very often a small injection of half an ounce of whisky in an ounce 
and a half of water, or even an injection of whisky, brandy, or sherry 
and water given alone, will be retained and completely absorbed, 
when a larger volume of fluid or other ingredients added to the 
alcohol will not be retained, and the whole enema will pass out 
again. Rum may be used, or brandy, but, as a rule, good whisky 
is the most serviceable. When alcohol is given in connection with 
other rectal foods, it may be unnecessary to dilute it with water, 
but undiluted whisky sometimes causes precipitation in milk. If 
added too strong it coagulates casein which has not been pancrea- 
tinised, and no solid matter, even in the form of a fine precipitate, 
is of much use in the rectum, where it acts as an irritant. 

PRESCRIPTIONS FOR FOOD ENEMATA 

Ewald recommends the following: Beat the whites of two eggs 
with a tablespoonful of cold water, add a teaspoonful or two of 
starch boiled in a half teacupful of a 20-per-cent glucose solution, 
a wineglassful of claret, and a teaspoonful of peptone solution. Mix 
at a temperature below the coagulation point of the albumin. 

Yeo prescribes expressed meat juice, egg albumin, and peptones. 

Leube prefers the mixture of scraped meat and fresh pancreas 
made into an emulsion as prescribed above (p. 408). 

Roberts gives milk gruel and beef tea, with two teaspoonfuls of 
liquor pancreaticus freshly mixed. He reports a case in which he 
sustained the patient's life for nine weeks upon this treatment alone. 

FOOD SUPPOSITORIES 

Rectal food suppositories are sometimes made of predigested 
and evaporated or condensed forms of milk or meat juice, which 
are mixed with oil or cacao butter and pressed into an elongated 
bougie or suppository. They sometimes prove useful, and are cer- 
tainly convenient, but they possess no real advantage over nutrient 
enemata, and if rectal feeding is to be long continued, the latter 
are found more practical. 

Inunction Foods 

Attempts are sometimes made to get nourishment into the body 
by means of inunction through the skin, and olive oil, cod-liver oil, 



MEDICINES AND FOOD 41 1 

and cacao butter are rubbed into the integument of the abdomen 
and thighs. This means is naturally only employed in cases of 
extreme emaciation from wasting diseases, such as carcinoma, 
marasmus, and phthisis. It has proved mainly useful with maras- 
mic infants, but it is doubtful whether it possesses any true value 
beyond the advantage of lubricating a dry and shrivelled skin, and 
retaining some of the body heat in case of great feebleness. 



Intravascular Feeding 

In extreme cases of collapse, where death has seemed imminent, 
nutrient injections have sometimes been given directly into the veins. 
Of late years, however, it has been shown that in collapse from 
haemorrhage, or from loss of fluid in the evacuations of Asiatic 
cholera and cholera morbus in infants, salt-water injections (a drachm 
to the pint) answer as well, and have the advantage of being much 
safer and easier of application. 

Hodder was the first to practise the intravenous injection of 
milk in 1850 for collapse from Asiatic cholera, and T. G. Thomas 
was among the first to inject warm milk into one of the veins of 
the arm. He reported one case in which eight ounces of milk 
administered in this way saved life. Both goat's and cow's milk 
have been so used, but the milk must be rendered alkaline. 

Down reports similar success. Fowler tried intravenous injec- 
tion of peptone solution, and has given as much as six ounces of a 
digested beef solution in this manner. The peptone does not re- 
appear in the urine, but the casein of milk does, as well as solutions 
of sugar or albumin when injected into a vein. Some of the fat drop- 
lets in milk have greater diameter than the capillaries, which might 
prove a practical objection to the injection of unskimmed milk. 



Hypodermic Feeding 

Feeding in cases of desperate exhaustion by hypodermic injec- 
tions of milk and of peptone solutions has been several times at- 
tempted, but the results, beyond the use of alcohol by this method, 
have not proved sufficiently satisfactory to warrant its continuance. 



MEDICINES AND FOOD 

Too little attention has been bestowed upon the mutual relations 
of food and medicines. So little is really definitely known of the 
intricate chemistry of digestion and assimilation that it is difficult 
to formulate rules for the right time of giving every drug in rela- 
tion to fulness or emptiness of the stomach. The reaction of the 



412 ADMINISTRATION OF FOOD FOR THE SICK 

stomach contents varies from alkaline to neutral and acid, and these 
several reactions will decompose medicines in various ways. Besides 
this, the reactions themselves are dependent upon a large number of 
organic acids, salts, and other substances which may wholly alter 
the composition of a medicine at one time, and not be present to 
affect it at another. 

A drug given after a full meal may be decomposed by the strong 
hydrochloric acid of active digestion, which is unaltered in an empty 
stomach. 

Conversely, remedies which are not themselves influenced by the 
gastric and pancreatic juices may affect these secretions as synergists 
or the reverse. Chittenden says : " Take, for example, the influence 
of such substances as urethan, paraldehyde, and thallin sulphate on 
the proteolytic action of pepsin-hydrochloric acid, and we find that 
small quantities (o.i to 0.3 per cent) tend to increase the rate of pro- 
teolysis, while larger amounts, say one per cent, decidedly check 
proteolysis. Similarly, among inorganic compounds, arsenious 
oxide, arsenic oxide, boric acid, and potassium bromide in small 
amounts increase the proteolytic power of pepsin in hydrochloric- 
acid solution, while larger quantities check the action of the ferment 
in proportion to the amounts added. Again, with the enzyme tryp- 
sin, similar results with such salts as potassium cyanide, sodium 
tetraborate, potassium bromide and iodide may be quoted as show- 
ing not only the sensitiveness of the ferment towards foreign sub- 
stances, but likewise its peculiar behaviour — viz., stimulation in the 
presence of larger quantities. Furthermore, we have found that even 
gases, as carbonic-acid and hydrogen-sulphide, exert a marked re- 
tarding influence on the proteid-digesting power of trypsin." These 
gases, being a product of intestinal malfermentation, may thus inter- 
fere with digestion. 

Hydronaphthol and bismuth salicylate retard gastric digestion. 
Sodium bicarbonate and other alkalies check pyrosis in chronic gas- 
tritis, which is caused by diminished hydrochloric-acid secretion, 
but increase pyrosis subsequently, because of the greater alkalinity 
produced, which favours the growth of lactic-acid organisms. Ac- 
cording to Leffmann and Beam, beta-naphthol stops the action 
of diastaste, but not that of the amylolytic ferment of pancreatin, 
hence it is useful as an intestinal antiseptic without wholly stop- 
ping digestion. It, however, retards proteid digestion. They also 
state that salicylic acid and saccharin both prevent the amylolytic 
action of diastaste and of pancreatin, but do not retard proteid 
digestion. 

These few examples are sufficient to illustrate the very diverse 
influence of some of the common drugs. 

The following rules are subject to many exceptions, but they 
will serve as a general guide : 



MEDICINES AND FOOD 413 



Rules for administering Medicines in Relation to 

Food 

1. Alkalies are best given shortly before meals, unless designed 
to neutralise hypersecretion of hydrochloric acid. 

2. Acids should be given within half an hour after meals. 

3. Bitters should be given before meals. 

4. Remedies such as iron and arsenic, which may prove some- 
what irritant to mucous membranes, should be given either soon 
after the regular meals or after taking some simple article of food. 
Ammonium carbonate and potassium iodide, for example, may be 
prescribed in milk. 

5. Most cough medicines, cardiac tonics, diuretics, and systemic 
remedies which are not especially irritating to the stomach should 
be taken between meals. They will be more promptly absorbed 
from an empty stomach, and are less liable to be altered in composi- 
tion by digestive fluids or to inhibit digestion. 

6. Remedies designed to act in the intestine and not in the 
stomach, such as salol, should be given at the end of gastric diges- 
tion, when the stomach contents are about to pass into the intes- 
tine. 

7. Saline laxatives should always be taken at least half an hour 
or an hour before meals, preferably before breakfast; but the 
stronger, more slowly acting cathartics should be given on an empty 
stomach at night. 

Cod-liver oil should be given an hour and a half after meals, or 
on an empty stomach before retiring. 

According to Whitehead, starchy food should be avoided while 
iodine preparations are being administered, because of the insoluble 
compound likely to be formed of iodine and starch. Syphilitics, he 
says, should therefore eat meat and light green vegetables only, in 
order to get a maximum effect from the remedy. If they are taking 
very large quantities, such as half an ounce or more a day, this may 
be advisable, but it is unnecessary for ordinary cases. 

Foods and beverages may be often used to disguise the taste of 
disagreeable or bitter medicines, especially for children. An un- 
pleasant dose may often be smuggled down in a teaspoonful of jam 
or a little molasses, and quinine is somewhat disguised by mixture 
in chocolate lozenges. It may be given in solution to adults in 
coffee. Castor oil is given floating on coffee or beer. Both milk 
and Vichy partially disguise the taste of potassium iodide. 

Milk is an excellent vehicle for powders, such as bismuth, mag- 
nesium carbonate, or sulphonal. Many bitter medicines may be 
followed by a lump of sugar or a strong peppermint lozenge, or the 
mouth may be rinsed with a little brandy and water. Chocolate is 



414 ADMINISTRATION OF FOOD FOR THE SICK 

also a good vehicle for the administration of bitter medicines, and 
it may be employed to emulsify cod-liver oil. 

DIET-KITCHEN OUTFIT 

When a case of protracted severe illness occurs in a household it 
is very convenient to improvise a small diet kitchen in a room next 
the patient's bedroom. The outfit should consist of the following 
articles, in addition to the usual receptacles for containing the food : 

A spirit or gas lamp kept ready to heat a porcelain-lined sauce- 
pan at any time, day or night. 

A double porcelain-lined saucepan for a hot-water bath. 

A cooking thermometer for use in hot fluids. 

A measuring glass to hold six or eight ounces. 

Pancreatin powders. 

A bottle of rennet ferment. 

Sodium bicarbonate, two or three ounces. 

Borax, half a pound (to clean utensils). 

A glass funnel with filter papers. 

A meat-mincing machine. 

A good chafing-dish and a pair of scales, although not necessary, 
are highly desirable. 

TRAINED PURVEYORS OF FOOD 

The training of food purveyors for hospitals, asylums, and other 
institutions has only quite lately received the attention which it de- 
serves, and hospital managers are awakening to the fact that it is 
truly economical to employ a skilful trained buyer who understands 
something of food values, dietetically as well as pecuniarily, and who 
studies the conditions of the market at different seasons of the year 
in order to secure variety of food at a minimum cost. To meet the 
constantly increasing demand for such persons, the Pratt Institute, 
of Brooklyn, offers a series of three-months' courses for both men 
and women, which are to cover the following topics : (i) The selec- 
tion of food material as to quality, food value, and cost. Marketing 
and buying by sample. (2) Methods of preparation in a large way 
and by appropriate apparatus. (3) The care of food, cold storage, 
etc. (4) Serving, embodying general dining economy, labour-saving 
appliances, etc. Field work, visits to public kitchens, and manu- 
factories of kitchens, and hotel furnishings. 



PART VIII 

DIET IN DISEASE— DIET IN INFECTIOUS 
DISEASES 



DIET IN FEVER IN GENERAL 

The general principles of the dietetic treatment of the condition 
of fever which accompanies many different diseases are conveniently 
studied collectively, while the special modifications of diet required 
for certain infectious fevers will be considered under their several 
headings. 

The cardinal principles of feeding the sick involve, first, the 
avoidance of all articles that disagree with the condition present, and 
second, the giving of the food best adapted to relieve the digestive 
organs of unnecessary labour and to maintain nutrition. In addition, 
for certain special diseases there are classes of foods which have 
distinctly curative value — for example, the use of fresh fruits and 
vegetables in scurvy, fats and oils in scrofula and tuberculosis. Al- 
though there is no curative food for fevers, it should be remembered 
that there is nothing so easily assimilated as water, and advantage 
must be taken of this fact to introduce other foods into the body 
with it, giving them therefore in fluid form. 

Pathological Physiology of Fever. — The former treatment of 
fevers by starvation and depletion, on the theory that the poison 
of the disease was soonest conquered by withholding all food and 
drink upon which it might thrive, and starving out " a devouring 
flame of inflammation," has long been superseded by more scientific 
methods. This early treatment culminated in France in the first 
part of this century, and was first combated in England by Graves 
and his successful followers. 

It is now known that in fevers by supplying the patient with 
abundant nitrogenous food the tissues of the body are spared from 
consumption — in other words, that the proteid matter of the food is 
burned up or oxidised instead of the proteid matter of the patient's 
muscles and other structures. The animal food thus given does not 
add to the substance of the tissues, but saves them from wasting and 
combustion. 

415 



41 6 DIET IN DISEASE 

Bauer believes that " the gravest possible injury to the organism 
of the fever patient may be brought about by a diet too rich in albu- 
minates," and to some extent carbohydrates and gelatin may be 
substituted for them, yet he adds that while " an exclusive use of 
albuminates is undesirable. ... In fever a larger relative proportion 
of albuminates is requisite than in health, and so much larger as the 
albuminous metabolism is greater." 

Fever patients commonly excrete much more nitrogen than they 
take in as food. In so doing it is believed that they first exhaust 
whatever reserve supply may be on hand in the food proteids pre- 
viously absorbed and circulating in the blood, and subsequently 
draw upon the tissues, just as is the case in starvation. The urea 
daily eliminated during fever may exceed by forty or fifty grammes 
the normal amount voided in the urine during health, and this may 
be the case even when no food is given ; hence the waste increase 
is mainly nitrogenous (Bauer). In chronic fevers with remissions, 
like tuberculosis, there is less rapid waste than in the continuous 
forms such as typhoid. If the digestion remains fairly good in any 
fever, the loss of body weight is proportionately checked. 

Voit suggested the theory that the tissues act somewhat after the 
manner of gland cells, and normally attract such albuminous sub- 
stances as they need without themselves undergoing any serious 
change, and Bauer believes that this hypothesis may be applied to 
the consumption of proteids in fever, " that under those conditions 
which the febrile processes bring with them the tissues yield up to 
the circulation a larger proportion of their own albumin, and that 
an abnormal amount of materials for metabolism is thus presented 
to the cells." The organs meanwhile lose proteids faster than in 
ordinary starvation, but by the same processes. A single albuminous 
meal adds more protein to the circulation, which in starvation would 
aid in restoring equilibrium ; but in fever it fails to do so, and the 
loss continues because the inflamed cells have for the time being 
lost their power of assimilation. Emaciation therefore proceeds. 

Another theory which has been strongly advocated, but which, 
on the whole, has less to recommend it, is that the inflamed cells 
consume and destroy proteid material from the blood at a much 
faster rate than in health, and supplying a purely proteid diet does 
not check the waste. The entire question is exceedingly intricate 
and difficult of solution. The experiments which have been made 
in febrile metabolism are somewhat contradictory, and it is undoubt- 
edly better to be guided at present by the results of clinical experi- 
ence in feeding fever patients than by theoretical formulae. 

This subject is physiologically very closely related to the paren- 
chymatous and fatty degenerations of organs which attend many 
diseases, but it is impossible within the practical limitations of this 
work to enter into this discussion, and the reader is referred to a 



DIET IN FEVER IN GENERAL 417 

very able presentation of these theories in the chapter upon Con- 
sumption in Febrile Disease by Bauer in his Dietary of the Sick 
{Handbook of General Therapeutics, v. Ziemssen). 

Leyden and Frankel believe that in fever more fat as well as 
more albumin is consumed than in health, but other authorities 
think that fat destruction does not keep even with albuminous waste. 

In fever the secretion of hydrochloric acid is diminished or sus- 
pended in the stomach, and its peristaltic action is so lessened that 
the food is apt to remain longer than it should and undergo mal- 
fermentation, causing oppression or pain, nausea, and vomiting. 
Absorption also is much reduced in fevers. The stomach may 
wholly give out, and, as Roberts observes, it becomes merely a 
conduit, so that the intestine must carry out the work of digestion 
unaided. 

Dietetic Treatment. — The conditions to be met in the dietetic 
treatment of fever are as follows : 

1. To save tissue waste by supplying sufficient nourishment. 

2. To give semisolid or fluid nourishment in a form which will 
not overtax the enfeebled digestive apparatus or leave a large residue 
for decomposition. 

3. To give abundant fluid with the object of relieving thirst and 
to wash out through the kidneys the waste matter produced by the 
increased rate of metabolism. 

4. In some cases, to give alcohol as a food as well as a stimulant. 
In all fevers presenting periods of remission it is desirable to 

give the greater portion of the food while the temperature is lowest, 
so that it will be better digested and absorbed, for at this time the 
tissues appear to temporarily recover their assimilative power to 
some extent. 

In mild cases, with remissions, if the appetite holds out, it may 
do no harm to allow some little variety in the diet ; but if the fever 
is brief and the appetite fails, it is unnecessary to force the patient 
to take food. 

As a rule, in fevers which are protracted or severe, nourishment 
should be given in fluid form. To offer solid food in serious fevers 
is practically to place foreign bodies in the alimentary canal which 
merely ferment and putrefy, causing discomfort with flatus, fetor, 
and diarrhoea. There are some exceptions to this, notably the fever 
of phthisis, some forms of protracted sepsis, and ague. 

Milk being the first and " natural food " of man, it would seem 
most appropriate that it should constitute the staple article of diet 
in fevers in which the digestive powers are temporarily greatly en- 
feebled or wholly suspended. The danger from its continuous and 
exclusive use arises from its coagulating in lumpy masses, which act 
practically as solid food, but the many means which are at the dis- 
posal of the physician and nurse make it possible to overcome this 



41 8 DIET IN DISEASE 

difficulty almost completely, and by processes of artificial digestion 
milk may be given ready for absorption, so that nutrition is rendered 
quite independent of stomach and intestinal digestion. In the ma- 
jority of cases, therefore, milk is altogether the best food. The 
methods of giving it have been described in the section upon 
Adaptation of Milk for the Sick (p. 73), and the reader is also 
referred to the section upon the Treatment of Typhoid Fever (p. 

426). 

Next in importance to milk in the diet of fever are to be men- 
tioned the various preparations of meat — infusions, extracts, juice, 
powder, broths, etc. (p. no). The fundamental idea of all such 
preparations is the solution of the nutritious myosin of the muscle 
fibres and its separation from the much less digestible sarcolemma 
and the connective tissue constituting the sheaths of the muscle fas- 
ciculi. These preparations may be made from tender veal, chicken, 
roast beef, and beefsteak. Clear soups or consommes are nutritious 
and mildly stimulating in fevers, but if given often or in large quan- 
tities patients usually tire of them, and they may be considerably 
varied by flavouring with vegetable juices and extracts or aromatic 
herbs, which afford variety, and as a rule do no harm, unless exhaust- 
ing diarrhoea be present. 

Buss gives the following mixture to fever patients : Peptone, 100 ; 
grape sugar, 300 ; rum or Cognac, 200 ; water, 600 grammes — the 
quantity to be taken in twenty-four hours m addition to milk, yolk 
of egg, bouillon, etc. If this food is too sweet, tincture of gentian 
is added. 

Purees may be given, made by thickening clear soup with well- 
cooked arrowroot, or finely ground rice, or thoroughly baked wheat- 
en flour. Bauer recommends the use of " fruit soups," which are 
prepared by boiling fruit, either fresh or dried, with the addition, if 
desired, of grape sugar, lemon peel, etc. The mass is then com- 
pressed and strained, and the fluid obtained has an agreeable taste 
and somewhat laxative action. 

In cases of moderate severity and short duration, when the di- 
gestive organs are not greatly disturbed, it is not necessary to 
confine the patient to fluids, although solid food, especially meats, 
should be withheld. Semisolid food may be given, such as milk 
toast, cream toast, soft-cooked eggs, beef jelly, or plain rice pud- 
ding. Thoroughly boiled oatmeal gruel sustains strength while un- 
dergoing severe physical toil, and fever has some resemblance to 
muscular effort in its temporary arrest of digestive activity, so that 
sometimes substances of this class prove useful from their support- 
ing power. 

Many other varieties of farinaceous and other carbohydrate foods 
are suitable in febrile cases when carefully prepared in fluid form. 
Patients often object to these substances for the reason that they 



DIET IN FEVER IN GENERAL 419 

are tasteless and monotonous, whereas if prepared with a little care, 
by giving proper attention to their flavouring, they may be made 
very palatable. Thin gruels of rice, oatmeal, or barley, from which 
all solid matter has been very carefully removed by straining through 
a cheese-cloth bag, may be salted and flavoured with any desirable 
aromatic, such as cinnamon, clove, nutmeg, lemon or orange peel ; 
grape sugar may also be added. Such gruels may be prescribed 
either alone or combined with meat extracts, or beef tea, or beaten 
eggs. The addition of grape sugar has been recommended by See 
and others because of its ready absorption, and from the fact that 
it is the form of sugar which is produced from the digestive fermen- 
tation of starches, and is to be regarded, therefore, as an easily 
assimilable carbohydrate which, to some extent, may prevent tissue 
waste by furnishing fuel to the body. 

If a patient be fed upon clear farinaceous gruels alone during 
fever, he cannot thus obtain over eight or ten grammes of proteid 
material per diem, or one twelfth of the quantity required by a 
healthy man at rest, and obviously he will suffer within two or 
three days from tissue waste and inanition. Egg albumin, meat 
broths, or gelatin must therefore be added, or the soups must be 
thickened. 

Eggs may be eaten, but they should never be boiled, and in fact 
they require but little cooking. They may be beaten with boiling 
water and strained and dropped into consomme or light broth or 
gruel. The yolk and the white may be used either separately or 
together. The yolk may be beaten with hot milk and water, or with 
hot tea sweetened with grape sugar (Yeo), or it may be added to 
brandy. The brandy mixture of the British Pharmacopoeia (mistura 
spiritus vini gallici, Br. Ph.) is made as follows : The yolks of two 
eggs with half an ounce of refined sugar are beaten and added to 
four ounces of Cognac and an equal amount of cinnamon water. 
The brandy in this mixture may be still further diluted or reduced 
to advantage. Some patients prefer to take eggs raw, while others 
prefer to have them very slightly cooked by immersing them in 
water which has been boiling, thus cooking them very slowh at a 
temperature not exceeding 180 F. for ten or fifteen minutes. Eggs 
prepared in this way are uniformly and lightly cooked, and the al- 
bumin is coagulated in a soft gelatinous mass instead of the hard, 
white, tough coagulum which is produced by greater heat (see 
p. 104). 

Cold meat jellies as well as simple sherry wine and lemon jellies 
may occasionally be given, but gelatin alone is not particularly nu- 
tritious, and, in proportion to the bulk occupied by this class of 
foods, comparatively little benefit is derived from them. 

Gelatin given with other foods, especially those of proteid com- 
position, is assimilated much better, and makes a desirable addi- 



420 DIET IN DISEASE 

tion to the dietary in mild cases. When added to milk in the form 
of blancmange patients usually enjoy it. 

Beef tea and chicken jelly in equal parts make an excellent com- 
bination. 

Beverages in Fevers 

The Value of Water and Other Beverages. — In almost all febrile 
affections the liberal use of water, or some beverage composed 
chiefly of water, is to be recommended both for the relief of thirst 
and on account of its diluent effect and of its increasing the facility 
with which the waste matter resulting from the rapid metabolism 
of the fever is eliminated through the kidneys. A dry mouth de- 
stroys the appetite. It is believed by many that the toxins pro- 
duced by the action of typhoid-fever germs or other micro-organ- 
isms are rendered less powerful and are in some degree " washed 
out " of the system by the imbibition of large draughts of water. 
Patients who are extremely feeble, or who are not wholly rational, 
niay not ask for drink although their mouths are dry and parched, 
and it should always be the duty of the nurse to give water in proper 
amount at regular intervals. In long-continued fevers there is a 
tendency for an increased loss of water from the surface of the 
lungs, and sometimes from the skin, although the kidneys may be 
less active than normal, and if care is not taken to replace the fluid 
in the body the effects of this loss become much more pronounced. 
If there are profuse watery evacuations from the bowels the drain 
of fluid from the blood, and eventually from other body tissues, is 
considerable. 

Sour lemonade constitutes one of the most useful and refreshing 
of beverages. It is not particularly apt to disorder the stomach, espe- 
cially if taken in the intervals between the ingestion of food, and to 
many persons it is exceedingly grateful. It may be made efferves- 
cing by the addition to a strong lemonade of Vichy, carbonic-acid 
water, soda water, or ten grains of sodium bicarbonate. 

Barley and rice water with a little lemon juice and sugar, or with 
cinnamon, wine, and sugar, afford refreshing drinks to many per- 
sons, especially children, but they contain very little nourishment. 
Either tea or coffee may be allowed once a day in many cases of 
fever, although this fact is often overlooked. Tea should be 
avoided if there is marked indigestion in the stomach, and coffee 
as well as tea should be avoided in cases where there is insomnia 
or excessive nervousness. If there is flatulency they should be 
given without sugar, and not with other food. Persons who ob- 
ject to the taste of milk may take it if a tablespoonful of good 
coffee be added to the tumblerful. Strong black coffee, moreover, 
is useful in controlling vomiting, and is mildly stimulating in cases 
of heart failure. Its diuretic action is also valuable in fever, but it 



DIET IN FEVER IN GENERAL 42 1 

should be remembered that those who are not ordinarily disagree- 
ably affected by the daily use of strong coffee may be made very 
nervous by even small quantities given when the system is reduced 
by the wasting processes of fever. Both tea and coffee should be 
used, therefore, with discretion, although they may at times prove 
valuable in relieving the monotony of a fluid diet. Other useful 
beverages are whey, or whey and beef tea, either hot or iced, and 
unfermented grape juice. 

For the immediate relief of thirst cracked ice may be given, 
but it sometimes parches the lips. Some patients prefer a glycerin 
mixture. A drachm or two of glycerin and half a drachm of borax 
or boric acid may be added to a tumbler of water and used to rinse 
the mouth. 

By sipping fluids, thirst is more relieved than if they are quickly 
drunk. There is more satisfaction in draining a small glass than 
in merely taking a few mouthfuls from a large tumblerful. 

The question of the temperature at which milk or any form of 
beverage should be given in fevers may safely be left, in most cases, 
to the liking of the patient. I have elsewhere shown (p. 333) that 
the body temperature can be but little if any affected by that of in- 
gested fluids, and it is a matter of far more importance to give them 
in so agreeable a form that they will not be refused. An excess of 
cold drinks may embarrass digestion or cause stomach cramps, and 
should be avoided, but any cold fluid slowly sipped will do no harm. 

Alcohol as a Food in Fevers 

The principal theory of the action of alcohol in all fevers is that 
it serves as a food ; it is readily absorbed and carried in the blood to 
all parts of the body, and it is believed that its combustion saves in 
some degree the wear and tear of the tissues, as the alcohol burning 
in a spirit lamp furnishes energy in the form of heat, and itself be- 
comes oxidised to waste products, but spares the carbon of the 
wick. The latter is not itself burned up or oxidised until the alco- 
hol has been exhausted. Another theory of the use of alcohol is 
that it possesses a positive antipyretic action by which it controls 
the body temperature by restricting heat production. It is also 
believed that alcohol in fevers acts upon the nervous system, 
strengthening and supporting it, in this manner indirectly con- 
trolling the nerve currents which preside over the activity of nutri- 
tion, chemical change, and heat production. The subject is a very 
broad one, and is obscured by the lack of definite knowledge as to 
the exact nature of the chemical processes concerned in heat pro- 
duction, which are probably very complex. It is possible that in 
many instances alcohol may act simultaneously in all the ways sug- 
gested, having the combined effect of a food, a nerve tonic, and an 



422 DIET IN DISEASE 

antipyretic. This view is ably advocated by Dujardin-Beaumetz, 
who gives an exhaustive discussion on the subject in his work on 
alimentation in fevers (Du Regime Alimentaire dans les Maladies 
Febriles, p. 227). 

Light white wines, diluted claret, and even beer are recom- 
mended in fevers by some writers on dietetics, especially in those 
countries in which good water is unobtainable, or in which for other 
reasons wine drinking is in much more common daily use than it 
is in America, where there is an abundant supply of pure water. 
In France and Germany light red wine is frequently allowed 
throughout the course of mild fevers, and from five to ten ounces 
are given daily. The fever diet in the Munich General Hospital 
includes 150 to 300 grammes of light red wine or white wine. Beer 
is also much used in Germany for fevers, and it contains some nour- 
ishment. 

If alcohol is not required for its stimulating effect upon the 
circulatory or nervous systems it is better to withhold it, for in 
continued fevers emergencies may at any time arise in which it is 
imperatively demanded to strengthen the failing powers or aid in 
controlling the exhaustion of delirium. Its influence will always be 
more decided and its action can be much better controlled if spirits 
have not previously been given, and when it is needed for any such 
reason it is best to prescribe it in the form of brandy or whisky. 

In general, it may be stated that alcohol is usually needed if the 
temperature remains for several days above 103 F., and is always 
required if it remains as high as 105 F. The typhoid condition 
supervening in the course of any fever always demands it — i. e., the 
condition characterised by great prostration, low muttering de- 
lirium, subsultus, rapid feeble pulse, dry tongue, etc. 

In the convalescence following prolonged fever the daily use of 
liquors with meals, or in the form of toddy or punches between 
meals, two or three times a day, is often indicated. This is particu- 
larly the case among elderly people convalescing from pneumonia 
and other acute febrile diseases or who have been greatly weakened 
by some prolonged adynamic disease. In infancy also, and early 
childhood, the use of alcohol may be demanded in the course of 
acute fevers. 

Persons who have been habitual though moderate drinkers for 
many years, or throughout their lives, when attacked with any 
severe acute or infectious disease possess less vitality and resistance 
than those whose tissues have not been constantly bathed in alcohol. 
To withhold the long-accustomed stimulation in these cases is often 
to precipitate serious exhaustion, and the problem of properly 
adapting the quantity of alcohol to the patients' actual needs be- 
comes a very serious one to the physician, to which he should give 
careful and thorough study. Caution should be given against the 



DIET IN FEVER IN GENERAL 423 

continued use of alcohol by patients in whom there is danger of 
inducing the alcohol habit. It not infrequently occurs that those 
who have been addicted to excessive drinking, but who have been 
temporarily cured of the habit, and who have taken no liquor for 
possibly several years, acquire some acute disease in which there 
is need of active stimulation. In such cases, having in view the 
possible recovery of the patient, with a renewal of his alcoholic habit, 
this stimulant should be withheld as long as possible while efforts 
are made to sustain the enfeebled heart power by strychnine, digi- 
talis, or diffusible cardiac stimulants, such as ether, ammonium 
carbonate, aromatic spirits of ammonia, camphor, etc. 

From the above account it appears that the question of the use 
of alcohol in all febrile disorders should be considered from two 
chief standpoints, embracing, first, its value as a food, with its rela- 
tion to other foods and to nutrition ; second, its value as a stimulant 
and the extent to which it may be replaced or re-enforced by drugs. 
The continued use of strong alcohol always disorders digestion, and 
since the stomach is weakened in fevers, it is more susceptible to 
such influences, and this is an additional argument for not employ- 
ing alcohol in a routine method, but for saving it for positive indica- 
tions, such as asthenia. But in those cases in which the battle for 
life must be waged largely with stimulants as much as one ounce 
an hour (twenty-four ounces per diem) of brandy or whisky must 
sometimes be given, and it is a curious fact that in the presence 
of high fever patients can often tolerate such dosage without the 
indications of alcoholic poisoning which in health would promptly 
follow the use of a smaller quantity. 

Diet in Convalescence from Fevers 

Convalescents who have long subsisted solely upon fluids must 
be careful in resuming solid diet, for the rapidity of recuperation of 
the digestive organs varies in different persons, and taking meats or 
other solid foods too soon may cause rise in temperature, rapid 
heart action, and possibly visceral congestion. The first meat given, 
therefore, should be in a finely subdivided state, such as scraped 
beef or minced chicken. 

During convalescence from protracted fevers the more easily 
digested forms of starchy foods are found to be very useful, es- 
pecially if there has been much loss of weight. Sago and tapioca 
thoroughly cooked and served with cream are highly nutritious, 
and dried bread crumbs rolled through a fine sieve may be added 
to thicken clear meat broths. Crackers and zwieback are useful. 

Other ingredients which may be added to thicken soups during 
convalescence are panada, semolina, tapioca, and macaroni. Cus- 
tard puddings, cooked fruit, wine and beef jellies, blancmange, or 
29 



424 DIET IN DISEASE 

baked custard may be allowed. " Mush," fine hominy, cornstarch^ 
farina, and boiled rice, with beef juice, can be ordered. 

The following dietary will serve as a general guide for feeding 
convalescents from fevers of ordinary severity in which special 
lesions of the alimentary canal are not present. It is taken from a 
Handbook of Invalid Cooking: 

"FIRST DAY 

" Breakfast. — Poached egg on toast. Cocoa. 
" Lunch. — Milk punch. 

" Dinner. — Raw oysters. Cream crackers. Light wine if de- 
sired. 

" Lunch. — One cup of hot beef broth. 

" Supper. — Milk toast. Wine jelly. Tea. 

"SECOND DAY 

" Breakfast. — Soft-cooked egg. Milk punch. Coffee with su- 
gar and cream. 

" Lunch. — One cup of soft custard. 

" Dinner. — Cream-of-celery soup. Sippets of toast. A little 
barley pudding, with cream. Sherry wine if desired. 

" Lunch. — Milk punch. 

" Supper. — Water toast, buttered. Wine jelly. Tea. 

"THIRD DAY 
" Breakfast. — Scrambled egg. Cream toast. Cocoa. 
" Lunch. — One cup of hot chicken broth. 

" Dinner. — Chicken panada. Bread. Light wine if desired. A 
little tapioca cream. 

" Lunch. — An eggnog. 

" Supper. — Buttered dry toast. Baked sweet apples and cream. 
Tea. 

"FOURTH DAY 

u Breakfast. — An orange. Oatmeal (H. O.), with cream and 
sugar. Poached egg on toast. Baked potato. Cocoa. 

" Lunch. — One cup of hot soft custard. 

" Dinner. — Potato soup. Croutons. A small piece of beef- 
steak. Creamed potatoes. Baked custard. Coffee. 

" Lunch. — One cup of chicken broth, with rice. 

" Supper. — Raw oysters. Banquet crackers. Graham bread,, 
toasted. Wine jelly. Tea. 

"FIFTH DAY 

" Breakfast. — An orange. Coffee. Oatmeal, with cream and 
sugar. Broiled mutton crop. Toast. 
" Lunch. — One cup of mulled wine. 



TYPHOID FEVER 425 

" Dinner. — Chicken soup. Bread. Creamed sweetbreads. 
Duchess potato. Snow pudding. Cocoa. 

" Lunch. — Siphon soda, with coffee sirup and cream. 

" Supper. — Buttered dry toast. Orange jelly. Sponge cake 
and cream. Tea." 

A further discussion of this topic will be found in the section 
upon Convalescence in Typhoid Fever. 

While brandy and whisky constitute the best form in which to 
give alcohol in the acute stage of fevers, in convalescence it is 
often advisable to use some other alcoholic drink, and an occasional 
change from one variety to another renders the patient somewhat 
less liable to the danger of acquiring a permanent alcoholic habit. 
For convalescence, if the patient's purse can afford it, champagne, 
port wine, sherry, Madeira, or a good claret or Burgundy, may be 
taken with advantage in the class of cases above mentioned. 

TYPHOID FEVER 

Pathological Physiology. — Careful nursing and diet regulation 
are the life-saving agents in typhoid fever. In few diseases does 
a closer relation exist between right feeding and symptoms. 

In average cases the fever lasts a month, no matter what the 
treatment, whether by cold bathing or otherwise, while in some it 
continues for five or even six weeks. There is then a convalescent 
period of at least two weeks, and often as many months, during all 
which time constant care in feeding must be exercised. At any 
time during the prevalence of the fever the slightest departure from 
the strict rules for diet laid down by the physician may determine a 
fatal issue, but it is during the period of ulceration that the greatest 
danger is met. 

The ulcers involve the Peyer's patches and solitary follicles in 
the lower end of the ileum, but they may extend into the jejunum, 
and even into the large intestine. They are deep and clean-cut, 
often including the whole thickness of the muscular layers, and 
sometimes perforating through the serous layer. An overloaded 
intestine or a distended bowel may precipitate perforation at any 
moment. It is therefore important to select a diet which will leave 
but small residue. 

More or less intestinal as well as gastric catarrh is often present, 
interfering with both digestion and absorption. 

The prolonged fever is itself a menace to life by the secondary 
changes which it induces in the alimentary system. The digestive 
secretions are altered in quality and lessened in quantity. En- 
feebled circulation retards or inhibits absorption, and the functional 
activity of the liver is in abeyance. 

Poisonous products suspended in the blood, as well as its ele- 



426 DIET IN DISEASE 

vated temperature, interfere with the normal rate of metabolism 
through the body, and finally the excretory organs are overworked. 
The typhoid bacillus has curious behavior in relation to certain 
food materials, e. g., if cultivated in milk it prevents coagulation ; 
whey cultures become distinctly acid, and potato cultures show 
peculiar modes of growth. 

Dietetic Treatment 

There are two chief factors which should influence the selection 
of a proper diet for typhoid fever. These are: i. The supposed 
danger of mechanically irritating the ulcerating surfaces in the 
intestine and the danger of overloading an intestine and stomach 
whose digestive functions are impaired by fever. 2. The relations 
of the chemical ingredients of the food to the increased tissue 
change that causes or accompanies the excessive production of 
heat. If the proper fuel can be furnished as food, the tissues are 
spared too great self-consumption in producing heat. 

Milk Diet. — In regard to the first factor the danger of mechan- 
ical irritation of the intestinal wall is somewhat exaggerated. In 
prescribing a milk diet for typhoid fever in order to lessen this 
danger many overlook the fact that undiluted milk, on entering the 
stomach, becomes almost solid, and large firm milk curds are likely 
to prove quite as irritating to the ulcerating surfaces, or even more 
so, than are starchy foods. 

When patients are fond of milk and digest and absorb it thor- 
oughly, there is no better diet for typhoid fever, and it answers 
every requirement of a fever food. It contains all the essential 
elements of nutrition, is easily digested, furnishes fluid to the tis- 
sues, is a good diuretic, and, if properly administered, in many cases 
it is soothing to the stomach when a mild degree of gastric catarrh 
exists. 

Those who dislike milk at first may later grow accustomed to it 
and take it contentedly for a month or even six weeks. 

Due emphasis should be given to the fact that an exclusive milk 
diet need not and should not be prescribed in routine for all cases. 
Within the past few years a number of writers (notably Shattuck of 
Boston and A. G. Barrs of London) have advocated a departure 
from the strict milk diet which had come to be the rule for typhoid 
fever, and it is found beneficial to enlarge the dietary of some pa- 
tients considerably by such articles as strained vegetable soups, 
boiled rice, macaroni, soft-cooked eggs, soft cream toast, cream and 
water, buttermilk, softened soda crackers, blancmange, wine jelly, 
and ice cream. It is much easier to put all hospital cases of typhoid 
fever on a routine milk diet, but it is often better to devote a little 
study to securing suitable variation in the food. 



TYPHOID FEVER 427 

In typhoid fever every effort should be made to maintain good 
stomach digestion. If all food is thoroughly disintegrated before it 
enters the intestine there need be little fear of a mechanical irrita- 
tion of the ulcerating surfaces. P^ar more danger may occur 
through malnutrition of the intestinal wall, which prevents absorp- 
tion of nutriment. An accumulation of undigested food in the 
intestine is therefore highly undesirable, and the stools should be 
periodically examined to see that undigested milk curds do not 
appear in them. 

Milk for some persons in health is really a poison. They com- 
pletely fail to digest it. It causes constipation with clay-coloured or 
white stools, and fills the bowels with products of malfermentation, 
ptomaines, and gases. They digest it even less when they acquire 
a prolonged fever. Others, with whom the milk agrees, become 
very tired of it after taking it exclusively for several weeks at a 
time. 

I have several times seen cases of typhoid fever with symptoms 
which resembled scurvy, with swollen and bleeding gums and great 
emaciation, occurring in patients who had been fed too long upon 
an exclusive milk diet which they failed to assimilate. 

Quantity of Milk Required. — If milk is the only food, enough 
should be given, and the problem of what constitutes enough must 
be solved in each case separately. Much harm is done by over- 
feeding, which induces indigestion and restlessness, increases the 
pulse rate, and aggravates the abdominal symptoms — such as tym- 
panites, diarrhoea or constipation, haemorrhage, and abdominal pain. 
Ingestion is very different from digestion. 

There are many writers upon dietetics who give a special cau- 
tion against the practice of overfeeding in cases of enteric fever on 
account of the fact that more or less gastric catarrh is usually pres- 
ent and that it is an undue tax upon the digestion of the patient to 
have to deal with a large bulk of food. 

On the other hand, underfeeding causes malnutrition, favours 
the occurrence of complications, and prolongs convalescence. 

For an exclusive milk diet the outside limits lie between one 
and three quarts per diem, depending somewhat upon the age and 
size of the individual, but more upon the condition of his digestion. 
A clean tongue, a soft abdomen, and natural milk stools, not too 
hard and without coagulse of casein or flakes of fat, indicate that the 
milk is being well digested. 

The reverse of these symptoms suggests that the milk is sup- 
plied in too large quantity, or that it is not being digested, and one 
or more of three things must be done : (a) The quantity must be 
reduced ; (b) the mode of administration must be changed — i. e., 
the milk must be predigested ; (c) other foods must be substituted, 
either wholly or in part. 



428 DIET IN DISEASE 

(a) When milk appears to be well digested, but the patient 
emaciates rapidly early in the disease, he is not getting nourishment 
enough, and the quantity must be increased or other food must be 
added. As a general rule, from one and three fourths to two quarts 
of milk per diem (or six ounces every two hours, day and night), 
however diluted, is sufficient during the height of the fever to sus- 
tain the patient properly. It is best to give as much as can be 
thoroughly assimilated according to the symptoms above noted. 

Johnston believes that from three to four ounces of milk given 
every two or three hours is sufficient. Moore states that very few 
patients digest over one and a half to two pints of milk, and " it is 
scarcely ever necessary to exceed the amount of one quart of milk 
in the twenty-four hours," or three ounces of milk in ten feedings at 
intervals of two and a half hours. This estimate, for uncomplicated 
cases at least, is too low. It may be necessary to reduce the allow- 
ance to this figure if severe gastro-intestinal disturbance occurs, or, 
in fact, with violent vomiting to temporarily discontinue the milk 
entirely, and give only cracked ice or half-ounce doses of iced 
champagne, but patients kept too long on as low a diet as that 
mentioned will emaciate, grow feeble to an alarming degree, and 
require excessive stimulation. 

(b) The milk may be given raw, boiled, diluted with plain water, 
barley water, lime water, Vichy, Seltzer, or Apollinaris, or pan- 
creatinised according to taste and need. Gelatin, as well as gum 
arabic, is sometimes added to milk to dilute it and prevent tough 
curds from forming. The milk should never be skimmed. Its 
taste may be disguised by the addition of a little strong coffee or 
some of the extract of coffee, or a little caramel makes it agreeable 
to the taste where patients have refused it before, or it may occa- 
sionally be preferred with a cup of cocoa in which the milk pre- 
dominates. If diarrhoea is present, a milk diet is especially useful, 
and the milk should be boiled. 

When vomiting occurs, it is better to use peptonised or pancre- 
atinised milk than soda or lime water, for the latter tend to neu- 
tralise the activity of an already enfeebled gastric juice. These 
fluids may be given either hot or cold, according to taste. If cold, 
the nausea is sometimes controlled, but digestion may be somewhat 
retarded. If the vomiting is very obstinate, koumiss, kefir, or zoo- 
lak may be given for a time with very good result in place of 
milk. Whey or buttermilk is also used sometimes for a change for 
a few days. A. L. Loomis recommended from four to six quarts of 
the latter per diem. 

(c) Substitutes for Milk Diet.— When milk is obviously dis- 
agreeing and producing flatulence, I have often seen improvement 
follow an entire change of diet for a day or two to animal broths. 
Similar results are familiar in the treatment of infantile diarrhoea. 



TYPHOID FEVER 429 

In cases like those above described in which, after fair trial, it is 
found impossible to urge upon the patient the taking of milk, there 
is no objection to giving strained broths of mutton, chicken, or 
beef, a little clam broth for a relish, and light farinaceous arti- 
cles, such as the prepared starchy foods, like Mellin's or Nestle's, 
barley water, farina, arrowroot, and other gruels, custards, egg- 
nog, or a piece of zwieback softened by soaking in milk, weak tea, 
or bouillon. I have used gruel made from banana meal, which 
.is palatable, highly nutritious, and easily digested (see p. 182). 
Junket and cream are very nutritious and agreeable to the palate. 
Egg albumin can be made very palatable by beating it with a little 
milk and sherry. In this manner considerable variety is secured 
.for the patient; the appetite, and in many cases the digestion, are 
improved, and by alternating one or more of these articles with the 
milk, a much larger quantity of nourishment will in the end be 
taken and absorbed. Layton estimates that typhoid patients may 
sometimes lose half a pound in weight per diem, and in that class 
of cases in which rapid emaciation is a most alarming feature of the 
disease these various adjuncts to the milk diet are especially useful. 
Moreover, patients fed in this manner are not likely to become rav- 
enous during convalescence. 

It is well expressed by Henry that " it is not so much solid as 
indigestible food that should be eschewed, and it should never be 
forgotten that all foods except such as are predigested are solid in 
the first stage of digestion." A pint of milk contains as much solid 
material as a mutton chop. 

The continued use of beef tea, beef juice, or meat extracts and 
peptonoids undoubtedly produces loosening of the bowels, and such 
substances must be avoided when diarrhoea is present ; but in cases 
where there is a tendency to constipation this may be a decided 
advantage. Veal and chicken broth are less apt to have a laxa- 
tive effect than beef and mutton broth, and calf's-foot jelly is 
allowed by some clinicians. When patients tire of the taste of beef 
tea or broth it may be flavoured with a little celery salt or, if there 
is no diarrhoea, with a very little tomato juice or other simple vege- 
table extract. 

Henry advocates the use of gelatin as an " albumin sparer/' 
although it should not be given if diarrhoea is present. As much as 
a claret-glass full may be given on alternate days, and it can be in 
the form of simple blancmange or peptonised milk jelly, which is 
made by adding, while hot, gelatin dissolved in a little water to pep- 
tonised or pancreatinised milk, and flavouring with lemon or orange 
and sherry or rum. It is eaten cold. In the stomach it is quite 
as fluid as predigested milk. 

Farinaceous Gruels. — I have alluded to the occasional advantage 
-of giving farinaceous gruels, for, despite the fact that many writers 



430 DIET IN DISEASE 

are opposed to them on the ground that they may excite tympany, 
I believe them to be at times of great service. Stromeyer feeds 
his patients largely upon oaten grits boiled for three hours with- 
out sugar. 

Da Costa recommended giving three pints of milk and one pint 
of broth every twenty-four hours, with a midday allowance of some 
gruel, such as arrowroot. There is a variety of enteric fever in 
which without any noticeable complications, and even without a 
very high temperature curve, emaciation is rapid and extreme. In 
such cases especially the use of farinaceous gruels is indicated. 
They must not be given too sweet, and a little cream or lemon juice 
may be added in lieu of sugar. It is often advisable to add a table- 
spoonful of malt extract, or one of the " prepared foods/' such as 
Mellin's, Horlick's, Ridge's, or malted milk may be given in milk. 

Sleep and Food. — In all cases of typhoid fever the question arises 
in regard to waking the patient at night for nourishment, or to take 
the temperature. 

Some patients awaken easily, are fed, and drop off to sleep again 
almost immediately. They may be fed every two hours day and 
night. Others, if awakened, do not readily fall asleep again, and 
lose half the night's rest or more, and this may considerably retard 
their recovery. It is sometimes best to let them sleep for three, or 
even four, hours without being aroused, for the rest may be of more 
value to them than food. So much depends upon the temperature, 
pulse, and general condition of each case that no rigid rule should 
be formulated, but it is best never to let four hours pass while the 
fever lasts without giving food. If patients are told that they have 
a little longer interval than usual in which to rest undisturbed, they 
will sometimes go to sleep at once. Of course, if they sleep during 
the day there is less need of postponing feeding by night. Con- 
stant drowsiness may indicate a need of more food. The nurse 
should always furnish a daily record of the exact amount of milk 
or broths actually given in twenty-four hours, making allowance 
for dilution, and this should be compared with the quantity of urine 
voided. 

Thirst. — Thirst is a prominent symptom in typhoid fever, and 
cool water should be given in abundance by the nurse, without wait- 
ing for the patient to ask for it. Water favours nutrition and the 
elimination of waste. If diarrhoea is absent it is well to acidulate 
the water with a little dilute phosphoric or hydrochloric acid, ten or 
fifteen drops to the tumblerful, or water flavoured with infusion of 
orange or serpentaria. Hoppe-Seyler has washed out the stomach 
in cases of typhoid fever, and shown that while the temperature re- 
mains high there is little or no acid contained in the gastric juice, 
and a mildly acidulated beverage may prove serviceable by aiding 
digestion as well as by relieving thirst. 



TYPHOID FEVER 431 

Relief of the latter symptom is sometimes sought by painting 
the tongue with glycerin, which is used to prevent evaporation from 
the surface and not because of any special virtue in the glycerin 
itself, which, in fact, is hygroscopic and tends to abstract water from 
the mucous surface unless it is already very much diluted, and it 
cannot protect it sufficiently from the evaporation which occurs in 
mouth breathing. The use of cracked ice in excess aggravates 
thirst rather than relieves it, and it is better to sip cool water at a 
temperature of 50 to 6o° F. rather than ice. The juice of a sweet 
orange or a lemon is often very acceptable, and in the absence of 
serious complications it can do no harm. Iced tea may prove 
agreeable. As a rule, it is well to restrict the use of effervescent 
drinks for the control of thirst on account of the danger of increas- 
ing flatulency, and stretching the ulcerated intestinal wall. 

In addition to the need of water for relieving thirst, it is of great 
service as a diluent for washing out the waste products of the febrile 
action from the system through the kidneys. Many clinicians, as 
Henry, Meigs, and Beverley Robinson, make it a special feature of 
their treatment to give large draughts of water. Henry advises 
giving each patient eighty ounces of water (including that con- 
tained in fluid food) per diem, and Meigs has given as much as one 
hundred and thirty ounces with benefit, including from thirty to 
fifty ounces of free water. Debove gives six ounces every two 
hours. It should not be drunk too soon after the fluid food, but in 
the intervals, so as not to dilute the gastric juice too much. In 
mild cases a little coffee or a cup of cocoa may be drunk in the 
morning. 

Alcohol. — The question of how far alcohol serves the purpose of 
a food and a " force regulator " in typhoid fever is very important. 
The employment of it in excess as a routine treatment is greatly to 
be deplored. It is seldom required at all in the first fortnight. 
Later the heart is enervated and its muscular tissue is enfeebled. 
In all complications which threaten life, such as severe haemorrhage, 
sudden cardiac dilatation, hyperpyrexia (107 F.), pneumonia, or un- 
controllable diarrhoea, alcohol must be given without stint. When 
the complication is passed the dosage should be gradually reduced. 

Patients above forty years of age usually require stimulation 
early. 

It was formerly customary to prescribe whisky in typhoid fever 
at the rate of twenty or twenty-four ounces per diem, and in some 
chronic alcoholic patients large quantities of alcohol may be needed 
to prevent collapse. Sometimes delirium will disappear when ex- 
cessive dosage of alcohol is discontinued, and I am inclined to pre- 
scribe very much less alcohol than formerly, especially for young 
and robust patients. Undoubtedly there are cases of greatly weak- 
ened circulation in which its use must be pushed rapidly, and in 



432 DIET IN DISEASE 

which it quiets restlessness, insomnia, and delirium better than 
opium or other narcotics, but it is not to be forgotten that there 
are other valuable cardiac stimulants. By giving small doses of 
digitalis or strophanthus, or the two in combination, by the use 
of caffeine, camphor, small doses of morphine, and other remedies 
in combination with alcohol, much less of the latter will be re- 
quired, and there is far less danger of inducing the alcohol habit. 
Strong whisky often intensifies the stomach catarrh and interferes 
with the natural absorption of food. One very noticeable feature 
of the Brand cold-bath treatment is that the patients do well with 
so little alcohol, many of them requiring none at all in the intervals 
between the baths. 

The kind of alcoholic stimulant prescribed must depend upon 
the circumstances of the case. Brandy and whisky possess the ad- 
vantage that the dosage is more uniform and the bulk is not great. 
It is a matter of routine hospital practice, founded largely on eco- 
nomical reasons, to give whisky or brandy as the only form of 
alcoholic stimulation, but in private practice, especially among 
women, liquors may be distasteful, and equally good results can 
be obtained by ordering some good strong wine which is more 
agreeable to the taste, such as one of the Hungarian wines, Malaga, 
port, sherry, claret, etc. In Germany patients are often allowed 
beer, but this beverage is open to the same objection as the effer- 
vescent drinks, for there is more or less gastric catarrh usually 
present. It is not much prescribed in this country. It serves bet- 
ter during convalescence than while the fever is present. Brandy 
in milk or soda or Seltzer water is best for diarrhoea, and dry cham- 
pagne is good if there is vomiting. As the latter is used in small 
doses — an ounce or less at a time — it is economical to place a 
patent cork with a faucet in the bottle, so that a little may be drawn 
at a time without losing all the effervescence. In any case in which 
alcohol is given the best guides for the proper quantity are found, 
as in pneumonia, in the breath, delirium, tongue, and pulse. If 
the breath has no odour of alcohol an hour or two after the dose 
has been taken, if delirium has subsided, if the tongue becomes 
more moist, and the pulse becomes more full and slow, the alcohol 
is doing good. 

During convalescence a little alcohol — two ounces of whisky 
or four or five of Burgundy a day, for example — may be needed as 
a tonic, but should be given onlv with food. 



Relation of Intestinal Antisepsis to Diet 

It is said that bacilli fed on beef juice produce ptomaines which 
act more strongly upon the nervous system than if they are fed 
upon milk (Rachford). The starches do not make ptomaines. 



TYPHOID FEVER 433 

The typhoid germs certainly thrive in nitrogenous media, but 
not upon carbohydrates. Their development in the former is ac- 
companied by the production of toxic material in the intestine, 
which, on being absorbed into the system, produces the symptom- 
atic phenomena of the disease. This theory, which is of compara- 
tively recent adoption, has emphasised the possible value of anti- 
septic treatment of the alimentary canal. While there are as yet 
no remedies known to therapeutics which can be used in sufficient 
strength in the intestine to be completely antiseptic or germicidal 
to the typhoid bacilli, there is another aspect of antisepsis, or rather 
asepsis, of the alimentary canal, which should not be overlooked — 
that is, the prevention of those fermentative changes which accom- 
pany indigestion in any fever. In typhoid fever the importance of 
maintaining as nearly as possible the normal digestion and absorp- 
tion of the food is of special urgency on account of the length of 
the disease. Moreover, it would appear that the overdistention of 
the intestine by flatus must have a very injurious effect upon 
the ulcerating surfaces by stretching them. At autopsies upon 
typhoid patients ulcers are often seen which might have been easily 
torn by slight distention, and the prognosis of typhoid fever is more 
grave when extreme and obstinate intestinal flatulency appears early 
in the disease, before there has been time for either perforation or 
peritonitis. One can do much to prevent this condition by bestow- 
ing special care upon the whole alimentary canal. 

Care of the Mouth. — The mouth should be washed very fre- 
quently at regular intervals, and always after taking a glass of milk, 
for nothing causes coating" of the tongue more than a milk diet, or 
forms a better field for the development of bacteria, which are con- 
stantly being carried down to the stomach to excite indigestion and 
flatulency there. Listerine and hydrogen peroxid make most satis- 
factory and cleansing mouth washes. A whalebone bent in a loop 
forms a good " tongue scraper," and cleans its surface quite thor- 
oughly. If patients are too feeble to rinse the mouth, the nurse 
should swab it out for them with a bit of cotton. Nurses should 
be made to understand the importance of this simple detail, for, 
if properly attended to, it adds greatly to the patient's comfort and 
appetite. When this is faithfully done, one seldom sees even in 
fatal cases a typical " typhoid tongue " — brown, dry, hard, fissured, 
and so stiff that it is useless to the patient. Patients can often 
learn to use a tongue bath to advantage — that is, to hold the mouth 
full of fluid for several minutes at a time, when much moisture is 
absorbed by the mucous membrane. The proper care of the mouth 
will greatly lessen the liability to parotitis and catarrh of the 
middle ear. 

The Stomach. — The dangers of overfeeding with milk have 
already been considered upon page 427. Milk disagrees with 



434 DIET IN DISEASE 

many patients sooner or later, and the fermentation processes of 
which it is capable produce large quantities of gas and sometimes 
elevation of temperature. Small doses of salicin or cerium oxalate 
with each tumbler of milk often prevent dyspepsia, and the milk, if 
sterilised, may be retained and digested where vomiting has been 
extreme. If there is the least indication of ordinary milk disagree- 
ing, it should be at once changed for some other form — peptonised, 
or sterilized, or boiled. With a clean tongue, and with sterilized 
milk in the stomach, much may be done to favour the further diges- 
tion of milk in the intestine. 

The Intestine. — Many typhoid patients are severely constipated 
by an exclusive milk diet. Constipation favours abnormal fer- 
mentation, and begets the flatulency which is so injurious. Such 
cases should not, as a rule, be allowed to go more than forty-eight 
hours without encouraging a movement with an enema. While it 
is not possible to render the alimentary canal in any sense truly 
aseptic throughout, a great deal may be done to favour the vital 
conditions of nutrition by preventing the opposite extreme of ex- 
cessive ingestion of bacteria of various kinds and the production 
of malfermentation. This appears to be at present a more encour- 
aging field for germicidal efforts than treatment directed against 
the seat of war in the Peyer's patches. The judicious daily use of 
rectal enemata never excites intestinal haemorrhage, but excessive 
constipation provokes meteorism, stretches the thin ulcerating sur- 
faces to the point of rupture, and tends to keep the temperature 
elevated. If relapses are due to reinfection or to simple septic 
absorption through ulcerating intestinal surfaces, there is all the 
more reason for the prevention of accumulation of too much food 
in the intestine. 

Convalescence. — As the fever subsides, it becomes an important 
question how soon to allow a return to solid food. Relapses are 
very easily induced by indiscretion in this regard. 

The patient's appetite is always a dangerous guide to follow in 
this disease. After four or five weeks of an exclusive milk or milk 
and broth diet, when the temperature subsides, and often before it 
has become normal, he becomes ravenous. Like a long-starved 
man, he thinks of nothing but food, and demands something new to 
eat every day. A hospital ward containing a dozen convalescing 
typhoid-fever patients is difficult to manage, as a bread riot is con- 
stantly menaced. Ill-advised but sympathetic friends attempt to 
smuggle in all manner of forbidden fruits, and the patient just ar- 
rived at the hungry state is tempted to steal solid food from his 
more advanced neighbour. 

In the milder cases it is undoubtedly both safe and wise to 
allow a strengthening diet at an early date, and it will greatly pro- 
long convalescence to forbid it. Light farinaceous diet — tapioca, 



TYPHOID FEVER 435 

rice, vermicelli, cream-toast, a cracker soaked in cream, etc. — may 
be given with impunity in cases which have run a mild course as soon 
as the temperature remains normal. Meat broths may be thickened 
with rice, sago, or vermicelli. In a day or two more the soft part of 
oysters or a chop are permissible. In cases which have presented no 
serious complications, if there is good stomach digestion there is no 
need of prolonging a fluid diet for fear of intestinal injury. 

The following is a list of foods suitable for the different days of 
convalescence, commencing a day or two after disappearance of all 
fever. Milk should still be given until gradually wholly replaced 
by solid food. 

First Day. — Chicken broth thickened with thoroughly boiled 
rice. Milk toast or cream toast once only during the day. Beef 
juice. 

Second Day. — Junket, mutton broth, and bread crumbs. Cocoa. 
Milk toast. A piece of tender steak may be chewed but not swal- 
lowed. One of the prepared farinaceous foods, such as Mellin's 
or Horlick's, may be given with a cup of hot milk. 

Third Day. — A small scraped-beef sandwich at noon. A soft- 
cooked Qgg or baked custard for supper. Boiled rice or potato 
puree strained. Arrowroot gruel. 

Fourth Day. — The soft part of three or four oysters. Meat 
broth thickened with a beaten egg. Cream toast. Rice pudding 
or blancmange and whipped cream, or Bavarian cream. 

Fifth Day. — Scraped-beef sandwich. A tender sweetbread. 
Bread and milk. A poached tgg. Wine jelly or calf's-foot jelly. 
Macaroni. 

Sixth Day. — Mush or crackers and milk, scrambled eggs, 
chicken jelly. Bread and butter. The soft parts of raw oysters. 

Seventh Day. — A small piece of tenderloin steak or a little breast 
of broiled chicken. Bread and butter. Boiled rice. Wine jelly. 
Sponge cake and whipped cream. 

Eighth Day. — A slice of tender rare roast beef, a thoroughly 
baked mealy potato served with butter or mashed with cream. 
Other foods as before. 

Ninth Day. — A little broiled fresh fish for breakfast. Beefsteak 
at dinner. Rice, macaroni, eggs. Sago, rice, or milk pudding. A 
baked apple. 

Tenth Day. — Mush and milk. A squab or breast of partridge 
or roast chicken. Other foods as before. Ice cream. 

For the next four or five days the patient may select articles 
from the menu of the previous day, so that three good meals a day 
are taken, besides three or four glasses of milk between meals. 

It is often desirable to give a little alcoholic stimulant, espe- 
cially if there is much difference in the frequency of the pulse 
between lying and sitting or standing, or if the pulse rate is very 



43 6 DIET IN DISEASE 

slow, say 56, as it sometimes is. A glass of sherry or of good 
sound Burgundy or a tumbler of ale may be drunk, but with 
meals only. 

Rules for Feeding in Atypical Cases. — If at any time during 
convalescence after several days of a normal temperature it begins 
to rise above ioo° or 100.5 F. it is safest to return at once to 
fluid diet. If the temperature falls again in a day or two, con- 
valescent diet may be resumed. A sudden rise to 103 F., or 
even higher, lasting but a day or two, may be caused only by 
constipation, and it is not to be considered as a genuine relapse, 
but until the cause is ascertained the above precaution must be 
observed. 

There is a class of patients in whom the thermometric record is 
likely to fail as a guide for feeding unless it is correctly interpreted. 
After a protracted fever lasting four or five weeks the temperature 
falls to about ioo c F. and fluctuates daily up to 100.5 or 101.5 F. 
without reaching the normal, or it may become subnormal and fluc- 
tuate between 97.5 or 98 F. in the morning, and 101 F. in the 
afternoon. These patients, in the absence of any sequelae to ac- 
count for the temperature elevation, have a " starvation fever," and 
they are usually considerably emaciated. It is necessary to give 
them solid food cautiously to bring the temperature to normal. 
Sometimes even then the fever lasts until they are allowed to 
sit up. 

In estimating the proper time for giving solid food, regard must 
always be paid to the general severity of the disease. 

Complications, such as an abscess or furunculosis, may protract 
the fever, although the intestinal ulcers are completely healed, and 
such patients should have solid food in spite of a slight elevation of 
temperature. Very mild cases, in which the fever curve subsides 
in ten days or a fortnight, are deceptive in that they are apt to 
relapse, and their fluid diet should be prolonged. Patients who 
have been very ill with repeated haemorrhage or hyperpyrexia 
should be fed with the greatest caution during convalescence. 

At the end of a fortnight of normal temperature, if the bowels 
are moving regularly and if there is no diarrhoea, the patient may 
usually be allowed to select his own menu, although he must be 
warned to avoid for a long time eating food likely to leave much 
insoluble residue, such as raw vegetables, raw apples, soft-shell 
crabs, berries, green corn, old peas, beans, cabbage, tough meats, 
dried fruits, etc. He must be instructed also not to excite diar- 
rhoea by eating too much fresh fruit. With any attack of indiges- 
tion he must return for a few days to a very simple diet. I have 
seen a second distinct relapse occur on the twentieth day after the 
first, but such cases are fortunately quite exceptional. 



TYPHUS FEVER 437 



Typhoid Fever in Children 

Typhoid fever in young children is rare. When it occurs in in- 
fants between two and five years of age they must be fed, if possi- 
ble, exclusively upon milk in some form, predigested if necessary, 
but in each case sterilised or Pasteurised. Children usually take 
koumiss well and thrive upon it. 

If milk is refused, and emaciation threatens in consequence, 
some concession should be made in the rigour of the diet, but of 
course no solid food can be allowed. Beef juice, beef, mutton, or 
chicken broths (not thickened), and beaten egg albumin sweetened 
and flavoured with a few drops of sherry, may be substituted for 
milk or alternated with it. Children take junket extremely well. 
When stimulants are required, from ten drops to a teaspoonful of 
brandy or whisky, well diluted, should be given. 

If they refuse this, a little Tokay, champagne or wine whey 
may be tried. As a rule they need no alcohol unless they are very 
feeble, or if complications arise. The nurse must offer water freely. 
Barley water with a little lemon juice is useful to relieve thirst. 

It must be remembered that the temperature curve of typhoid 
fever in children is often very regular, and a fall to near the normal 
must not be regarded as justifying an allowance of solid food at 
once, and no matter how clamorous the child may be for it, exactly 
the same rigid rules must be enforced as in the case of adults, and 
for the same length of time during convalescence. 



TYPHUS FEVER 

In general the dietetic treatment of typhus fever should be the 
same as that of typhoid fever, but as intestinal ulceration is absent 
from the former, the extreme care of the alimentary canal is less im- 
perative. The fever is high and the patient is usually delirious, 
hence an exclusive milk diet is best during the height of the fever, 
provided it is well digested. The duration of this fever is much 
shorter than that of typhoid fever, and some of the objections to a 
milk diet are therefore less apt to arise. From four to six ounces of 
milk may be given every two hours. 

If the milk is not well assimilated it may be alternated with or 
supplemented by broths, custard, raw eggs, farinaceous gruels, etc. 

Abundant water should be offered, and the prominent tendency 
to ataxic symptoms and stupor may be counteracted by strong 
black coffee, alcohol, etc. 

Convalescence. — During convalescence the precautions ob- 
served in the treatment of typhoid fever are not necessary, and 
patients may return much sooner to a solid diet ; but some alcoholic 
stimulant, such as ale or porter, will be needed with the meals. The 



43§ DIET IN DISEASE 

directions given in the section on Diet in Fever in General (p. 
417) may be observed; for, although any severe fever may leave the 
digestive organs somewhat enfeebled, there is no unusual danger 
of this kind in typhus fever, and relapses are not occasioned by 
dietetic errors. 

SMALLPOX 

The invasion of smallpox is usually abrupt, and the tempera- 
ture may reach 104 F. on the first day. There are anorexia, thirst, 
vomiting, and prostration, in addition to other symptoms. The 
fever continues for three days, or until the eruption has fully devel- 
oped, after which it subsides. During the febrile stage a light fluid 
diet should be given, such as is recommended for fever in general — 
milk, broth, gruel, etc. (p. 417). The thirst is usually consider- 
ably relieved by taking cool liquids in abundance, such as water, 
iced lemonade, Seltzer water, etc. If there is much eruption in the 
throat, there may be considerable dysphagia. 

During the suppurative stage of the eruption the patient re- 
quires an abundant supporting diet, and as much milk, eggs, whisky, 
and stimulating meat broths should be prescribed as can be di- 
gested. The patient should be fed at least once every two hours, 
and must be awakened three or four times at night for food. Vom- 
iting is not to be dreaded after the onset of the disease. The com- 
bined effect of the irritation of so large a cutaneous eruption, and 
of the secretion of so much pus from the pustules, which may 
amount to many ounces, is exhausting to the last degree, and ear- 
nest effort must be made to counteract it. This is especially true of 
all confluent cases. A dozen eggs, three quarts of milk, and ten 
or twelve or more ounces of whisky or brandy is not too much to 
order for an adult. These materials may be given alone or in com- 
bination, as eggnog, milk punch, etc. If the stomach rebels against 
so much food, the rectum must be utilised for part of the work. 

This supporting treatment should in all severe cases be com- 
menced early, even in the vesicular stage of extensive eruption, 
without waiting for signs of exhaustion, which are otherwise certain 
to follow. If strong liquor is not tolerated, champagne or other 
wine must be substituted. 

Convalescence occupies from one to four weeks, according to 
the severity of the attack. The diet should be slowly increased, and 
should comprise abundant animal food, meat, milk, and eggs, and 
alcoholic stimulants, such as ale, porter, or Burgundy. 

SCARLET FEVER 

In mild cases of scarlet fever the temperature subsides in a few 
days, and after that time, during the period of desquamation, spe- 



MEASLES 439 

cial care in the diet is unnecessary unless nephritis is present. 
While the fever lasts the diet should be of fluid character, and milk, 
koumiss, soups, broths, and farinaceous gruels of arrowroot, farina, 
etc., are to be given. In all cases there is liability to renal irrita- 
tion, and desquamative nephritis may occur ; and in order to elimi- 
nate the scarlatinal poison and waste products of the fever from 
the system as rapidly as may be, it is advisable that the patient 
take as little nitrogenous food as possible, except milk, and drink 
large quantities of fluid. Dryness of the mouth and thirst are prom- 
inent symptoms, and there is often difficulty in swallowing, owing 
to the inflamed condition of the throat. Water, effervescing waters 
(Seltzer, Apollinaris), barley water, orange juice in Vichy, and sour 
lemonade may be drunk in considerable quantities. 

In mild cases a little plain vanilla ice cream is much enjoyed by 
children. It is nutritious, cooling, and grateful to the parched 
throat. 

If the fever is high, four or five ounces of fluids must be given 
every hour. In severe cases there is gastric derangement, and the 
diet must be restricted to milk in some form, as koumiss or pepto- 
nised milk. If nephritis is present, the milk diet should be con- 
tinued, and all other nitrogenous food must be withheld (see Albu- 
minuria). Jaccoud maintains that scarlatinal nephritis can be usu- 
ally averted by keeping the child upon a strict milk diet from the 
commencement and continuing it for several weeks. 

Convalescent children who have had very mild attacks are often 
hungry, but it is best to control their diet carefully for two or three 
weeks, even if albuminuria is not detected. They may be given at 
first such articles as junket, rice pudding, crackers, farina, corn- 
starch or sago with cream, milk toast, cream toast, baked custard, 
blancmange, wine and beef jelly, mush, baked apples, stewed 
prunes, oranges. The resumption of animal fare should be very 
gradual in all cases, and fish, oysters, chicken, or eggs should be 
given before meat. 

MEASLES 

The diet in ordinary cases of measles does not require special 
care beyond that described under the section on Diet in Fever in 
General. The appetite is usually wanting in the prodromal and 
eruptive stages, and milk with farinaceous gruels answers every 
requirement. Thirst is prominent, and cool water or lemonade may 
be offered, or orange juice or unfermented grape juice in Vichy. 
Alcoholic stimulation is only needed if the patient is very feeble, or 
if severe complications arise. The resumption of a solid diet must 
be gradual, but it may begin as soon as the fever and catarrhal 
symptoms disappear. 

When nursing or hand-fed infants have measles they should be 
30 



440 DIET IN DISEASE 

fed somewhat oftener than usual, and must be given less food at 
each feeding. A child of eight or ten months of age should be fed 
on diluted milk like one two or three months younger. 'In this 
manner any existing catarrh of the stomach is less likely to cause 
serious indigestion and vomiting. It is particularly necessary to 
give water, and half an ounce should be offered at least every two 
hours, or oftener, while the infant is awake. 

If there is much gastric irritation or catarrh, it may prove best 
to suspend milk feeding for a day or two and substitute meat juice 
or beef or mutton broth. 

MUMPS 

For mumps no special diet is required beyond the necessity of 
giving fluids or soft food while the swelling of the parotid glands 
and fever last. The suggestions for the dietetic treatment of ton- 
sillitis apply to this disease. Anaemia is apt to be extreme during 
convalescence, and meats should therefore be plentifully supplied. 
Cod-liver oil is very appropriate in protracted convalescence. 



WHOOPING COUGH 

In whooping cough the paroxysms of coughing are so severe as 
to give rise to vomiting, and in bad cases they are excited by taking 
food which does not have an opportunity to become assimilated, 
and nutrition may suffer very seriously in consequence, adding to 
the general exhaustion which accompanies the disease. All food 
must be made easily assimilable. It is best to give food regularly 
in moderate quantity at each time, and it should be predigested 
if necessary. Pancreatinised milk, koumiss, the prepared amyla- 
ceous foods, cream toast, eggs, junket, chicken broth, malted farina- 
ceous foods, custard, milk puddings, gruels thickened with meat 
extracts, and stimulants in the form of Qgg albumin in sherry, egg- 
nog, or milk punch, are recommended for patients who vomit solid 
food. The worst cases require nutrient enemata, as exhaustion be- 
comes critical. 

INFLUENZA 

Symptoms. — Influenza is an acute and moderately infectious 
fever of microbic origin which is recognised by catarrhal inflam- 
mation of the mucous membranes of the upper air passages, and by 
symptoms referable to the nerve centres. In many cases the symp- 
toms are mild and of short duration, and no special dietetic treat- 
ment is required beyond that common to febricula, but a large 
number of cases are accompanied by a variety of serious complica- 
tions or they present sequelae. In the majority of instances the 
mucous membranes of the air passages are the principal seat of the 



INFLUENZA 44 1 

inflammation, but in others the gastro-intestinal mucous membranes 
are similarly attacked, giving rise to pronounced digestive dis- 
orders, nausea, vomiting, and diarrhoea. The fever, commonly of 
moderate severity (103 to 103. 5 F.), persists for three or four days 
or a week. There is usually great depression of spirits, with ex- 
treme malaise, muscular pains, enfeebled circulation, and almost 
total loss of appetite. As an adjunct to other treatment, absolute 
rest in bed is imperative in all severe cases, not only for the pur- 
pose of maintaining a uniform temperature and of protecting the 
body from draughts, but to guard against syncope from debilitated 
heart action. 

Dietetic Treatment. — While the fever lasts, the stomach is usu- 
ally irritable, and the diet must be fluid and restricted. Food should 
be given in very small quantities, according to the rules applicable 
in cases of extreme debility. 

In severe cases it is necessary to prescribe an exclusive milk diet 
for the first two or three days, and two and a half quarts should 
be drunk if possible. Later the patient may be given nourishing 
beef, mutton, or chicken broths, with beaten eggs added, milk toast, 
custards, eggnog, and milk punch. As soon as solid food can be 
eaten, scraped-beef sandwiches, oysters, tender breast of chicken, 
eggs poached or scrambled, and light farinaceous articles with which 
cream is taken, are appropriate. 

As a stimulant, champagne is particularly serviceable in relieving 
both the physical and mental depression which is so characteristic 
of nearly all phases of this disease. 

Convalescence is frequently prolonged, and debility, muscular 
weakness, irritability of the heart, and enfeeblement of digestion are 
often present to a degree which appears wholly disproportionate 
to the intensity and duration of the febrile attack. The diet must 
therefore still be carefully supervised, while every exertion of either 
body or mind must be prohibited. The food should be of a highly 
nutritious character and served in an appetising and palatable man- 
ner, and as abundant as the condition of the stomach will allow. 
(See Convalescence from Typhoid Fever, p. 434.) 

Patients with whom milk usually agrees do well to take it in 
quantities amounting to a quart a day, in addition to abundant solid 
nitrogenous food, roast beef, beefsteak, chicken, eggs, etc. 

Alkaline waters should be drunk. If the appetite flags and return 
of strength is delayed, tonics and possibly change of air may be 
required. 

When convalescence is protracted it is advisable to continue 
alcoholic stimulation, and milk punches, plain whisky and water, or 
a glass of sound Burgundy may be given two or three times a day, 
as a tonic, with the meals. Malt liquors may also be indicated in 
some cases. 



44 2 DIET IN DISEASE 



DIPHTHERIA 

Symptoms. — Diphtheria is an acute, infectious disease charac- 
terised by croupous inflammation of mucous membranes which 
particularly affects the pharynx and upper air passages. Clinic- 
ally the disease presents fever of an irregular type, with great 
debility, and frequently albuminuria. Anaemia and rapid, loss of 
flesh and strength are characteristic. The mortality is high, espe- 
cially among children, whom the disease chiefly attacks, and death 
may result from toxaemia, sudden heart failure, obstruction to the 
entrance of air caused by accumulation of the diphtheritic mem- 
brane, the extension of the inflammation down the air passages, or 
exhaustion from inability to swallow food. Recovery is uniformly 
slow, and may be still further retarded by paralysis or other sequelae. 
Owing to the extent to which the throat is involved, with conse- 
quent difficulty in swallowing, and to the general weakness and pros- 
tration, there are few diseases in which greater care in regard to 
dietetic treatment becomes imperative. There is anorexia, and the 
sense of taste is lost; nausea is frequently present as well as con- 
stipation. The cervical lymphatic glands are more or less swollen 
and give rise to pain or soreness on opening the mouth. Albumin 
may appear in the urine as early as the second day. 

Dietetic Treatment. — " Alimentation occupies the first place in 
the general treatment " (Trousseau). Throughout the active stage 
of the disease while the fever lasts, there is difficulty in swallowing. 
All food must be given in fluid form, of which milk is the best, or 
if, as sometimes happens, semisolid material is more easily swal- 
lowed, the food must be thickened with cream, gelatin, eggs, or 
farinaceous articles ; or beef meal, Mellin's food, malted milk, etc., 
may be added for this purpose to other foods. The diet should con- 
sist chiefly of nutritious beef or chicken broth and beef tea, ^gg 
albumin, eggnog, milk, and milk punch. Plain vanilla ice cream 
is nutritious, and if not too sweet it is well borne, and is frequently 
very grateful to the inflamed throat. Simple farinaceous foods, such 
as arrowroot, thoroughly cooked rice, soft cream toast, and gruels, 
may be taken. Continued disgust for food is a very bad prognostic 
sign, and every effort must be made to counteract it by offering 
variety. When the child is unable to swallow on account of pain 
or accumulation of membrane in the throat, forced feeding with a 
nasal or stomach tube may be better than nutrient enemata. 

Intubation and Tracheotomy 

When intubation of the larynx has been performed the child 
sometimes experiences great trouble in swallowing without drawing 
food into the trachea. It is difficult to close the epiglottis with the 



DIPHTHERIA 443 

tube in position, or to draw up the larynx beneath the root of the 
tongue to the extent which should occur in normal deglutition, and 
hence fluid food particularly is liable to trickle through the tube into 
the trachea, exciting violent dyspnoea and spasms of coughing. 
Semisolid food or solid food, such as junket, mush, or eggs, is more 
liable to glide over the instrument without being sucked in through 
it during inspiration. Patients usually require considerable nourish- 
ment to support their strength, so that the difficulties of feeding may 
be serious. 

Very young infants, who are dependent upon a milk diet, can 
swallow best if laid upon the back across the nurse's lap with the 
head downward supported below her knees. While in this position 
the bottle is given. Regurgitation through the nose may occur, 
but that is of little moment compared with the accident of inhaling 
the milk through the tube into the lungs. 

In older children, when proper precautions are taken in regard to 
the position of the head in swallowing and the avoidance of inspira- 
tion at the same time, these dangers may be reduced to a minimum, 
or they may be overcome by the passage of an oesophageal tube, 
though this irritates the throat and may spread the diphtheritic 
membrane along the oesophagus. Intelligent children can learn to 
swallow well with a little practice and care while wearing the intuba- 
tion tube. Some even swallow easier than before its insertion by 
reason of the relief of dyspnoea, which always makes deglutition 
difficult. In other cases the tube may be temporarily removed, if 
the dyspnoea is not extreme, while the child takes nourishment ; but 
this requires skilled attendance, and, as the patient must be very 
frequently fed, it possesses great disadvantages. As a rule, the 
longer the tube remains in position, the better the patient acquires 
facility in swallowing. In some cases it may be well to resort to 
rectal alimentation for a day or two to obviate the necessity of swal- 
lowing while the tube is worn. 

The late Dr. O'Dwyer said : " Solids and semisolids, when there 
is an appetite for such food, and when the patients can be induced 
to take it, are swallowed much better than fluids, and do not enter 
the tube, as far as I am aware " ; and he added that a bolus of food 
tends to press the epiglottis down over the tube, while fluid tends 
to raise it, or slip in under it, although he modified the head of the 
tube by giving it a concave surface to fit the epiglottis. 

It should not be forgotten with very young children that a failure 
to take food may be due to loathing or nausea, and not to physical 
inability to swallow with the tube in situ. O'Dwyer wrote : " I always 
instruct children who are old enough to understand, to drink as 
rapidly as they can, and then cough to expel any fluid which may 
have entered the tube, instead of coughing after each deglutition, 
as they usually do." He discountenanced the theory that food may 



444 DIET IN DISEASE 

enter the tube and excite pneumonia by reaching the deeper por- 
tions of the lungs, and said : " I do not believe — and there is no 
evidence so far to prove — that any of the fluid entering the tube 
ever reaches the bronchi, for it is promptly expelled by coughing." 
He cited cases in support of this statement, one being that of a 
woman who wore the laryngeal tube for over ten months continu- 
ously, and enjoyed good health. He said that vomited food enters 
the tube even less often than swallowed food. 

TRACHEOTOMY 

The operation of tracheotomy is performed for obstructions of 
various kinds, such as accumulation of diphtheritic membrane in the 
larynx, oedema of the glottis, laryngeal new growths, etc. The con- 
ditions which require this procedure are usually among those which 
interfere to a greater or less extent with swallowing, although the 
presence of the tracheotomy tube in the trachea is well borne and 
does not necessarily conflict with deglutition in any manner. No 
special precautions in feeding are necessitated by the presence of 
the tube, as in the case of intubation. 

Post-Diphtheritic Paralysis 

In post-diphtheritic paralysis the soft palate is oftenest affected, 
but the muscles of the tongue and pharynx, or even the oesophagus, 
may also be involved, in which case deglutition is hindered and the 
patient must be fed through a catheter or stomach tube (see Gavage) 
or by enemata. (See Food Enemata.) Meltzer has shown that in 
man and the horse the mylo-hyoid muscles contract upon fluids so as 
to squirt them down into the oesophagus at a rate exceeding that of 
ordinary peristaltic motion, or several feet a second ; hence, in paral- 
ysis affecting these muscles fluids can scarcely be swallowed. W. B. 
Cannon and A. Moser, by means of the X ray, studied the swallow- 
ing of capsules of bismuth, and found that " solids and semisolids are 
slowly carried through the entire oesophagus by peristalsis alone." 

The phenomenal success of antitoxin inoculations in reducing 
the mortality of diphtheria to less than one third of its former degree 
have made sequelae of this nature very infrequent. 



CEREBRO-SPINAL MENINGITIS 

Symptoms. — Cerebro-spinal meningitis is an infectious disease of 
microbic origin, in which the chief lesions are an inflammation of 
the meninges of the brain and spinal cord. This inflammation of the 
membranous coverings of the nervous system results in the produc- 
tion of a variety of symptoms, including fever, disturbances of the 
nervous and muscular systems, nausea, vomiting, and constipation. 



ERYSIPELAS 445 

The symptoms vary greatly in severity and duration, lasting from 
a few days to several months. In mild cases convalescence is estab- 
lished at the end of a week, but in severe and protracted cases the 
nervous symptoms increase m severity. The stage of excitement 
and irritation of the nerves with active delirium is succeeded by 
profound prostration and coma, with progressive emaciation, a vari- 
able temperature, and paralysis of the sphincters, with involuntary 
evacuations. Such cases as a rule prove fatal, but they are not 
necessarily hopeless, and recovery may occur at any time. Much, 
therefore, depends upon the careful nourishment of the patient, and 
every effort should be directed towards maintaining strength and 
promoting nutrition. 

Dietetic Treatment. — In mild cases a liquid diet of milk, broth, 
meat, and egg albumin, with, perhaps, a little toast or crackers, may 
be given while acute symptoms last. In protracted severe cases, and 
especially where convulsions, delirium, and coma are present, the 
patients must be fed with great care, and all nourishment must be 
given in frequent small doses and in an easily assimilable form. 
Huebner sometimes employs forced feeding with the stomach tube. 
Pancreatinised meat broth, pancreatinised milk, albumoses, and beef 
juice must be ordered, if necessary, every fifteen minutes. Brandy 
or whisky is required when hyperaemia is succeeded by exhaustion. 
If given too early, alcohol may increase the delirium. In extremely 
feeble patients such fluids must be administered in teaspoonful doses, 
or even in smaller quantities, with a medicine dropper, by which 
they are passed between the closed teeth. It will be also advisable 
to employ rectal alimentation. There is seldom any lesion of the 
alimentary canal present, and consequently in those cases in 
which larger quantities of fluid nourishment, or even solid food, 
can be taken there is no objection. If the patient is able to eat 
and swallow properly, milk toast, scraped beef, eggs, custard, 
wine jelly, farina, Bavarian cream, blancmange, etc., are indicated. 
Water may be given ad libitum to relieve the thirst, which is often 
severe. 

Convalescence will be promoted by giving abundance of food. 
Five or six meals a day may be taken. The appetite is frequently 
good from the commencement of convalescence. Beefsteak, chops, 
roast beef, mutton, or chicken, bread and butter, oatmeal, por- 
ridge, hominy, and rice with cream, may be allowed as soon as 
the patient's digestion admits. A milk punch, or glass of claret 
should be ordered three times a day. 



ERYSIPELAS 

Symptoms. — Erysipelas is an infectious disease caused by a spe- 
cific micrococcus, and characterised by high fever and intense local 



446 DIET IN DISEASE 

inflammation of the skin and contiguous mucous membrane. There 
is usually more or less prostration and enfeeblement of the heart 
and circulation. 

Dietetic Treatment. — The indications for dietetic treatment are 
to support the strength by stimulants and nutritious foods, which 
must be adapted for easy digestion. When the temperature is high, 
and nausea and vomiting exist, nourishment should be taken in 
small quantities — an ounce or two at a time every hour. In ordi- 
nary cases, pancreatinised milk, beef peptonoids or albumoses and 
beef juice, eggnog, milk punch, and farinaceous gruels are recom- 
mended. Alcohol is needed and it is well tolerated, for it seems to 
be consumed in the system without intoxicating effects. From 
eighteen to twenty ounces of brandy or whisky may be given within 
twenty-four hours. In extreme cases an ounce an hour may be 
taken, or if allowance is made for sleep the individual doses may 
be increased. The liquor should be diluted with plain water, or with 
Vichy or carbonic water, or soda water. Aged or debilitated per- 
sons and young children especially need vigorous alcoholic stimula- 
tion. After the local inflammation subsides the period of convales- 
cence requires a very nutritious diet, and fluids may gradually be 
replaced by beef, soft-cooked eggs, toast, bread and butter, and light 
farinaceous foods with cream. 

If the disease invades the pharynx, an exclusive milk diet is 
necessary, and alcoholic stimulants as well as medicines, except those 
designed for local treatment, should be given per rectum to avoid 
increasing the local irritation. 

Heuter favours the drinking of large quantities of hot tea to 
induce perspiration, but it is doubtful whether this in any way affects 
the cutaneous lesion. 

CHOLERA 

Dietetic Prophylaxis.— Cholera is a zymotic disease, the germs 
of which can only enter the system by the mouth, and they are 
spread chiefly through the agency of contaminated water used for 
drinking or washing purposes. All raw foods and cooking utensils 
washed in such water are liable to become infected. 

No raw food or drink of any kind whatsoever should be taken. 
In many cities it is customary for the local health boards to pro- 
hibit the sale of raw fruits while a cholera epidemic is in progress. 
It is a standard rule to cook all food and boil the drinking water. 

Tea, coffee, chocolate, and cocoa should be made only with water 
previously sterilised by boiling. Sterilised water only should be 
used for cleansing the teeth. Water should not be cooled by direct 
contact with ice, or the latter should be newly made from distilled 
water. No beer, ale, soda water, or artificial mineral waters should 
be used if there is any chance of contaminated river or well water 



CHOLERA 447 

having entered into their manufacture. Milk may become infected 
from washing the milk cans in impure water. 

Acid beverages should be freely drunk, for the cholera germs 
do not thrive in acid media, and if accidentally introduced into the 
stomach they may perish there if the gastric contents always have 
an acid reaction. Sour lemonade made with ten or fifteen drops 
of dilute sulphuric acid has an excellent reputation as a prophylactic 
against cholera. Vinegar, sour pickles, or lime juice may be taken 
for the same purpose. 

Indigestion, perhaps because it promotes alkaline fermentation 
in the stomach, favours infection, and hence during the prevalence 
of an epidemic it is desirable to eat only plainly cooked, wholesome 
food, and to avoid all excesses in eating and drinking. All foods, 
such as pastry, fried dishes, etc., having the reputation of easily 
disagreeing should be eschewed. 

During the prevalence of an epidemic of cholera it is highly 
important to avoid eating anything likely to produce diarrhoea, and 
all indigestible substances, such as meat, eggs, fish, or milk not 
strictly fresh, unripe or overripe fruit and vegetables, must be abso- 
lutely forbidden. 

Symptoms. — The symptoms of cholera are usually divided into 
four typical periods, which are those of— 

i. The premonitory diarrhoea. 

2. The period of profuse serous diarrhoea. 

3. The algid stage, or that of collapse or asphyxia. 

4. The reactionary stage. 

The dietetic treatment varies with each of these stages of the 
disease. It is imperative that the patient be kept absolutely quiet 
in bed throughout all the active phase of the disease. 

First Period. — There is alkaline watery diarrhoea with frequent 
profuse stools, nausea and, usually, vomiting. The stomach is too 
irritable to retain food, and undigested broths and milk only furnish 
culture media for development of the cholera bacilli and production 
of toxins. 

During this period only light fluid food in very small quantity 
should be eaten. Nothing can be worse than overeating. Whey, 
gruels, bouillon, or pancreatinised milk only are permissible. 

The contents of the stomach should still be kept acid, and sour 
lemonade, lime juice, dilute acid phosphates, dilute vinegar, and 
dilute hydrochloric acid, twenty or thirty drops in a half tumblerful 
of water, or diluted aromatic sulphuric acid in similar dosage, are 
to be swallowed from time to time. The acids should be given 
through a glass tube to spare the teeth. 

Hyperacidity of the stomach artificially produced favours the 
passage of a portion of the acid stomach contents into the small 
intestine, so that its normal alkalinity is, to some extent, neutralised. 



44§ DIET IN DISEASE 

The duodenum indeed may temporarily acquire an acid reaction, 
which is inimical to the development of cholera germs. 

Second Period. — The stools become more frequent and serous. 
They are almost continuous, and enormous quantities of fluid are 
rapidly drained from the system, in which whitish flakes of desqua- 
mated intestinal epithelium are suspended. Sometimes they contain 
blood. As much as two quarts of fluid may be discharged in a single 
evacuation. Nausea and epigastric distress occur with projectile 
vomiting of fluid, which exceeds in quantity that which is drunk. 
Intense abdominal cramps follow and extend down the legs. The 
patient rapidly emaciates, and the feebleness and prostration are ex- 
treme. There is a cold clammy perspiration, and in a few hours 
the victim passes into collapse. Active efforts must be made to 
stop the vomiting and diarrhoea. The abdomen must be incased in 
flannel, and turpentine stupes are of service if the cramps are severe. 
A mustard paste may be placed over the epigastrium, and a hypo- 
dermic injection of morphine is required. Cracked ice, cold lime 
water, iced champagne and carbonic-acid water, iced fresh lime juice 
in Vichy, weak cold brandy and Seltzer, or plain soda — are all good 
remedies which should be offered in very small doses every five or 
ten minutes. Strong black coffee may be tried. The thirst may be 
assuaged by dilute hydrochloric acid or lemon juice in water. A 
little fluid held in the mouth for a few minutes sometimes affords 
more relief of this symptom than larger quantities swallowed. It 
is worse than useless to attempt to give even predigested milk while 
the vomiting and diarrhoea continue. 

Third Period. — In both the second stage and in the third stage 
of collapse the best results are obtained by the method of hypoder- 
moclysis — that is, of hypodermic injections into the thighs and sides 
of the abdominal wall of large quantities of normal salt solution 
made by dissolving 60 grains (a scant teaspoonful) of salt to the 
pint of boiled water. The injections are given at the temperature 
of the blood, and the entire quantity may be used in the course of 
half an hour. The salt solution replaces to some extent the fluid 
drained by the serous diarrhoea and emesis, restores the blood pres- 
sure and equilibrium of the circulation, and almost immediately re- 
lieves the thirst. 

Fourth Period. — If vomiting ceases and the symptoms of col- 
lapse abate, a little fluid nourishment must be very slowly and cau- 
tiously tried. A teaspoonful or two of pancreatinised milk, koumiss, 
Liebig's or Valentine's meat extract, or fresh beef juice is first given. 
If this is retained, the dose is to be repeated and continued by in- 
creasing the quantity and diminishing the frequency of administration 
as the patient improves. The stomach remains feeble and irritable 
for many days, and for a week or two it may be necessary to limit 
the diet to predigested milk, beef albumoses, nutritious broths, egg 



YELLOW FEVER 449 

albumin in diluted brandy, and champagne. The further dietetic 
treatment may be conducted in the manner of that of the convales- 
cence of typhoid fever (p. 434). 



YELLOW FEVER 

Symptoms. — Yellow fever is an acute, infectious disease charac- 
terised by a sharp febrile paroxysm, gastric haemorrhage, jaundice 
and suppression of urine. The nature of the symptoms is exceed- 
ingly acute and intense. In those patients who die very soon after 
the invasion of the disease no definite lesions are found. In other 
cases hyperemia and visceral degenerations are noted. These im- 
portant changes are found in the liver and gastro-intestinal mucous 
membrane, and during the active progress of the infection digestion 
becomes almost impossible. The liver presents the lesions of paren- 
chymatous hepatitis. The hepatic cells here and there are rilled with 
granular material and oil globules. Many of them are distended or 
fused and have indistinct or absent nuclei. The small bile ducts are 
filled with degenerated epithelium, and the functional activity of the 
liver is therefore almost completely suspended. The whole alimen- 
tary canal presents the picture of acute catarrh, but the stomach par- 
ticularly is softened, swollen, and ecchymotic, and it may be eroded. 

The disease presents three different stages, the dietetic treatment 
of each of which is important, and it will therefore be necessary to 
briefly describe them. These stages are : 

1. The cold period, followed by febrile reaction. 

2. Remission or " stage of calm." 

3. Second exacerbation, a uraemic condition or else collapse. 
The first stage begins with almost immediate vomiting and great 

prostration. The ejecta consist first of mucus, then bile in increas- 
ing amount, and finally, if the retching continues and muscular 
straining is severe, the irritability of the stomach in this period be- 
comes greater than in almost any other disease. The slightest pres- 
sure over the epigastrium excites projectile vomiting. Constipation 
is present from the inability to retain fluids ; the mouth becomes dry 
and the gums sore and swollen, and thirst is extreme. The urine 
is much diminished in volume as the changes in the liver progress, 
and the bile ducts are blocked with degenerated epithelium ; the bile 
enters the blood, and the skin and conjunctivae become decidedly 
jaundiced. 

After several days — usually four or five — these symptoms sub- 
side and the second period is reached. The duration of this period 
seldom exceeds two days, and it may continue but a few hours. It 
is a condition of calm, in which all symptoms are abated ; the fever, 
which may previously have existed, subsides and the gastric irrita- 
tion is lessened. 



450 DIET IN DISEASE 

The third period promptly succeeds the second, and in it the 
symptoms of the first period return with renewed severity, and in 
addition a condition of uraemia develops. Haemorrhage of the 
stomach, known as " black vomit," is present in about one third of 
the fatal cases. The vomited material ejected during the course of 
the disease consists, first, of whatever food the stomach may con- 
tain, then of bile-tinged mucus, and finally of a deep brown or 
black acid semifluid substance resembling coffee grounds, which 
consists of red blood-corpuscles, pigment granules, degenerated 
mucus, epithelial ceils, leucocytes, fatty matter, and serous fluid. 
The action of the gastric juice upon the extravasated blood pigment 
turns it dark brown or black. The quantity of this fluid may reach 
several pints. It is acrid and irritating to the fauces and mouth. 
The blood from the passively congested surface oozes freely from 
the capillary walls of the gastric mucous membrane. The intestinal 
mucous membrane may be similarly affected, in which case the stools 
are black and diarrhceal. The urine becomes very scanty, and may 
be entirely suppressed. There is haematuria. 

Should recovery result, the jaundice continues for some days, but 
the other symptoms subside gradually and convalescence is always 
slow and may be retarded by various complications, among the most 
serious of which are an exceedingly irritable stomach and intestine. 
Errors in diet have been known to cause fatal haemorrhage from 
the stomach as long as a fortnight or three weeks after beginning 
convalescence. The heart action after such a severe ordeal is always 
feeble, and reparative and nutritive processes advance slowly. Irri- 
tability of the stomach may even persist for several months after the 
subsidence of all other symptoms. This brief account of the more 
important features of the disease emphasises the necessity for most 
careful dietetic management. 

Treatment of the First Period. — The patient must be immediately 
put to bed and kept absolutely free from excitement. Rest in a 
recumbent position must be carefully enjoined, and the patient must 
not be allowed to even raise the head to drink. Medicine and fluids 
must be given through a tube or with a teaspoon. If the patient is 
seen promptly, and there is a probability of undigested food being 
present in the stomach, that organ should be unloaded by an emetic, 
and as little medicine as possible should be ordered. If constipation 
is present the bowels should be emptied by a purgative enema. It 
is generally considered that profuse perspiration is an advantage. 
This object can be accomplished by covering the patient with blank- 
ets and giving a hot lemonade or hot toddy, such as hot whisky and 
water. 

As the vomiting becomes more and more severe, efforts may be 
made to relieve it, but if all measures fail, it will be best to let the 
stomach have absolute rest, which is secured by hypodermic injec- 



YELLOW FEVER 45 1 

tions of morphine, mustard paste over the epigastrium, and the use 
of the rectum for all medication. Among the various means at com- 
mand for the relief of the vomiting are cracked ice, light acidulated 
and effervescing draughts, such as acid lemonade, Vichy, Seltzer, 
or carbonic water, strong coffee, plain lime water in frequent half- 
ounce doses given cold, besides dilute hydrocyanic acid, cerium 
oxalate, etc. Iced champagne, very dry Mumm or Pommery sec, 
or acid lemonade with bitartrate of potassium, will sometimes be 
retained. With the supervention of uraemic symptoms, or when 
there is suppression of urine, there is urgent need of getting more 
fluid into the body. The lumbar region should be cupped or poul- 
ticed or covered with a mustard paste. If aerated waters are not 
tolerated by the stomach, three or four pints of salt water should 
be injected into the rectum every two hours, or it is suggested 
that hypodermoclysis might prove of service after the manner 
employed in cholera (p. 448). While the fever lasts, or through- 
out the first period, it is usually best not to attempt to give 
food at all, for the stomach is almost certain to reject or fail to 
digest it. 

Cochran dissents somewhat from the prevalent practice of allow- 
ing no food during this stage, and believes that an attempt should 
be made to supply a little nourishment per os, to fortify the system 
against the future drain upon it which is certain to follow. He says : 
" I have seen infants at the breast pass through attacks of yellow 
fever to prompt recovery, throwing up black vomit frequently and 
freely, and nursing as regularly and heartily as if there was nothing 
the matter with them." 

Many cases of yellow fever occur among previously healthy 
people who can withstand the absence of food for a day or two 
without serious loss, provided exhausting symptoms can be held in 
check. In many instances, however, prostration and exhaustion 
occur with extraordinary rapidity, and in an hour the patient may 
be too feeble to articulate or move. Active stimulation by the 
rectum and hypodermically is then necessary. For this purpose 
whisky is best. It should be obtained pure and injected hypoder- 
mically with a sterilised syringe in quantities of one to three 
drachms. The injections may be made beneath the skin on the 
outer surface of the thigh and arms in four or five places. Two 
ounces of whisky diluted in an equal part of water may be injected 
per rectum. 

Treatment of the Second and Third Periods. — During the interval 
of the second period abatement of the fever and of the gastric irri- 
tation may admit of a little nourishment being taken by the stomach. 
Some patients recover without passing into the third period, but 
because many do not, extreme caution must be observed and food. 
if taken at all, must be in very minute quantities. The same rules 



45 2 DIET IN DISEASE 

in regard to diet and stimulants apply to the third period which have 
been prescribed for the first, and the main reliance for nourishment 
should be through rectal alimentation. When the paroxysm is over 
and the symptoms have abated, the greatest care must still be exer- 
cised in regard to diet even if the patient is hungry, as sometimes 
happens. In the worst cases no solid food should be permitted for 
at least ten days or a fortnight, and it must be remembered that fatal 
relapses have been precipitated by not observing this rule. When 
the vomiting and epigastric pain have ceased, half-teaspoonful or 
teaspoonful doses may be given once in fifteen minutes of pancre- 
atinised milk, koumiss, Liebig's or Valentine's meat extract, iced 
dry champagne, or good Rhine wine. If such foods are retained, 
they may be followed after some hours by a few spoonfuls of pressed 
beef juice, salted, and later still by warm, nourishing beef broths, 
chicken broths, gruels, or buttermilk. Stimulating or nutrient ene- 
mata should still be ordered, because in the early stages of convales- 
cence the stomach will not tolerate all the food which the impover- 
ished tissues require. Any epigastric fulness or distress, or tym- 
panites, should be regarded as a warning, and food should be again 
withheld until the difficulty is corrected by antacids or antifermen- 
tatives. 

It is to be noted that children usually require rectal feeding and 
stimulation even earlier than adults. Large doses of opium given 
to aid the retention of nutrient or stimulating enemata should be 
avoided on account of the tendency to suppression of urine. In 
mild cases, after four or five days, and in severe cases after a fort- 
night, solid food may be occasionally given, commencing with milk- 
toast, crackers, junket and cream custard, farina and boiled or broiled 
chicken, soft-cooked eggs, wine jelly, boiled rice, scraped beef, and 
similar nourishment. 

Fruits and vegetables should not be allowed for several weeks. 



SEPTICEMIA 

In all septic conditions the diet must be made as nutritious as 
possible, and alcoholic stimulation may be required, brandy or 
whisky being the best forms. As a rule, the diet must be fluid, but 
in very chronic cases and those accompanied by prolonged local 
suppuration easily digestible solid food — such as broiled fish or 
beefsteak or chicken, oysters, toast, light bread and butter, and 
light farinaceous articles with cream — may be allowed. The di- 
rections given in the article upon the Diet of Fever in General 
(p. 417) and convalescence are applicable here, and if the patient 
improves, the stimulating diet recommended for some cases of 
tuberculosis (see Dietetic Treatment of Tuberculosis, p. 457) is 
recommended. 



TETANUS 453 



MALARIA 



Intermittent Fevers. — The dietetic management of malarial fevers 
consists of the treatment during the paroxysms and of that between 
them. In intermittent fever the paroxysms, although severe, are 
comparatively brief. Vomiting often accompanies the chill. If the 
patient is disinclined to take food there is nothing to be gained by 
urging it upon him, and the stomach may be allowed to rest for 
a day. Otherwise a glass of milk or a cup of broth may be given. 
When the paroxysm is over, if the appetite returns, solid food may 
be given without much restriction. If a patient has had several 
attacks at brief intervals he is usually both anaemic and constipated, 
and the subsequent diet should contain a liberal proportion of ani- 
mal food to counteract the former condition, and of fresh fruits and 
green vegetables for the latter. Beyond these general directions 
but little is usually necessary. 

Remittent Fevers. — In the continued malarial fevers, indigestion 
or feeble digestion may be a prominent symptom, requiring a milk 
diet while the fever is at its height. The reader is referred to the 
article upon the Diet of Fever in General (p. 417), which will cover 
the ground for these cases. 

Patients with malarial fever are inclined to resort too freely to 
the whisky bottle, and overstimulation in the continued fevers is a 
common fault. Only the severer forms of Southern and tropical 
agues, bilious remittent fever, etc., require much alcohol. The die- 
tetic treatment of the latter corresponds with the directions given 
for that of yellow fever (p. 450). 



TETANUS 

Symptoms. — Tetanus is an acute infection produced by a bacillus 
which enters the body through an abraded surface, develops toxins 
in the system, and causes greatly exaggerated irritability of the 
central nervous system. With the heightened reflexes, tetanic con- 
traction of the voluntary muscles occurs, especially of those of the 
jaw, face, and the extensors of the back. The ordinary reflex action 
from peripheral excitation is so far intensified that the slightest 
pressure on the surface of the body, or change in surrounding tem- 
perature, or even a loud sound, may throw the patient into violent 
convulsions and painful tonic spasms. Efforts in swallowing may 
induce them. The muscles of the jaw are often set in a condition 
of rigid contraction, making it impossible for the patient to open 
the mouth to take food, and forcible efforts to separate the teeth 
excite convulsions. It is necessary to support the strength by every 
available means, for tetanus is not invariably a fatal disease, al- 



454 DIET IN DISEASE 

though, according to Gowers, death results in about 90 per cent of 
all cases. 

Dietetic Treatment. — Food can only be given in liquid form, but 
if a front or side tooth is absent a soft-rubber catheter may be passed 
in between the set teeth and fluid can be conveniently poured into 
the mouth through it. Milk, egg albumin, eggnog, nutritious beef, 
mutton, or chicken broths, malted gruels, wine, brandy, and whisky 
should be given as frequently as the condition of the patient will 
admit. If possible, from two to four ounces should be administered 
every hour. The spasm does not affect the involuntary muscles, so 
that food is swallowed if it can be placed far back in the pharynx. 
Alcoholic stimulation and nourishment can also be given by the 
rectum, but this method is as apt to excite convulsions as mouth 
feeding. If severe convulsions are induced by every attempt to feed 
the patient, it becomes necessary to put him under primary anaes- 
thesia by the inhalation of chloroform, and then a tube may be 
passed into the stomach, through which twelve or sixteen ounces 
of soup or predigested milk, eggnog, and stimulants may be poured. 
By this means he is disturbed much less often and larger quantities 
of nourishment are taken at one time. In a recent case of tetanus 
which came under my observation, and in which tetanus bacilli were 
found, the muscular spasms were intense and almost continuous for 
over five weeks. The difficulty in feeding the patient was extreme, 
and emaciation was very pronounced. He complained incessantly 
of thirst, and often of hunger, but he was able to swallow milk broths 
and stimulants given between the closed teeth in very frequent doses, 
and his final recovery was attributable mainly to persistent efforts 
at careful feeding, chloroform anaesthesia having been several times 
successfully employed to relax spasm. 



RABIES 

In feeding a patient with rabies, substantially the same plan is 
to be followed as that above described for tetanus. In some cases, 
however, even in the early stages, all efforts to swallow fluid food 
excite violent general convulsions. Osier suggests that this spasm 
may be lessened by application of cocaine to the throat, so that the 
patient can swallow. Failing this, nutrient enemata must be relied 
upon, but they also sometimes excite convulsions. In this case it is 
justifiable to produce primary anaesthesia with chloroform, and to 
seize the moment of temporary relaxation for feeding. 

TUBERCULOSIS 

Causation. — Tuberculosis is an infectious disease, due to the 
presence in some part of the body of the Bacillus tuberculosis. The 



TUBERCULOSIS 455 

disease may be either acute or chronic, but fever is present when- 
ever there is an exacerbation of the symptoms. The latter are both 
local and general, and vary with the particular organ or organs 
affected, but the lungs constitute by far the most frequent site for 
the development of the germs. The bacillus produces from the tis- 
sue or " soil " in which it grows a toxin or poisonous substance 
which enters the circulation by absorption and which modifies nutri- 
tion, causing pyrexia and an increased production of tissue waste, 
with more or less rapid emaciation. 

Several factors combine to disturb the digestive system. These 
are : 

1. The fever itself. 

2. The impoverished condition of the blood, which affects the 
quality and quantity of the digestive juices. 

3. In pulmonary tuberculosis, after the expectoration becomes 
considerable it is often ropy and tenacious, and some of it is liable 
to adhere to the surface of the mouth or pharynx, and be swallowed 
with the food or saliva, with the result of exciting gastric and intes- 
tinal catarrhs, or possibly of locally infecting the mucous mem- 
brane of the intestine with the bacilli, which produce ulceration 
with further impairment of digestive functions and absorption. 

The prognosis of a given case depends very largely upon the 
digestion. 

General Consideration of Dietetic Treatment. — Proper dieting is 
unquestionably one of the most important factors in the prophy- 
lactic as well as the active treatment of pulmonary tuberculosis, and 
in prescribing a regimen many things must be taken into considera- 
tion besides the mere classification and selection of food. The dis- 
ease may be exceedingly protracted, lasting for years, with intervals 
in which the patient enjoys a comparative degree of health and 
comfort, which temporarily emancipate him from dietetic restric- 
tions. But even then he should see to it that his food is ample for 
his bodily needs. Malnutrition at any time may permit the renewed 
activity of a latent tubercular process, and, on the other hand, an 
increase in body weight is accompanied by marked improvement in 
the symptoms of the disease. 

The disease being very chronic the pecuniary circumstances of 
the patient must be considered. By ordering him to abandon his 
only means of livelihood or to undertake a long and expensive 
journey he may be so impoverished that he cannot afford to procure 
the best food, which is so essential both to repair the tissue waste, 
which sooner or later is a prominent feature of the disease, and to 
supply energy ; and good climate is of little use unless it helps him 
to acquire a better appetite and easier digestion. 

The appetite, too, must be consulted. It is sometimes better to 
humour whims than to seek to combat them, and inflexible rules 
31 



456 DIET IN DISEASE 

can no more be enforced for dieting- than for medication. The ap- 
petite is often very poor or capricious, and the physician's dietetic 
expedients will be severely taxed to devise suitable foods which 
meet all requirements. The patient should be given a list of foods 
which he can regularly eat, foods to be avoided, and foods which he 
may have as an occasional indulgence. 

Young phthisical girls especially may long for sweets and 
confectionery, and despise the more wholesome animal food ; in 
fact, some writers regard this as a symptom of the disease in such 
cases. If they cannot have what they crave they will refuse what 
they are allowed, and much tact and persuasion is required to in- 
duce them to eat rationally. 

Since so much depends upon sustaining the nutrition and 
strength of tuberculous patients, it is of the utmost importance to 
keep the stomach and bowels in the best possible condition. 

Patients should be warned never to swallow 7 the sputum, for 
this always excites dyspepsia, and sooner or later gastric catarrh. 
The occurrence of the latter is also favoured by the habit, which 
many patients acquire, of perpetually taking cough medicines and 
patent " sure cures," many of which contain potassium iodide and 
other gastric irritants. In advanced cases the catarrh may be a 
sequel to enfeebled circulation. 

All food should be fresh and carefully selected, and the cooking 
should be as simple as possible without monotony. Viands should 
be savoury, and served in a manner to tempt the palate. 

The most important articles of diet for the consumptive are the 
animal foods, and milk, beef, and fats and oils should form the 
essentials, rather than too much meat; but in ordinary cases any 
variety of properly cooked animal food may be eaten. Starches 
and sugars are allowable in milder cases, but never to the ex- 
clusion of nitrogenous aliments, and not at all if gastric catarrh 
exists. 

In phthisis there often seems to be a failure to assimilate amy- 
laceous and saccharine food, which is beyond that which is ex- 
plainable by the presence of catarrhal conditions. These substances, 
which ordinarily furnish a large proportion of the energy of the 
body, in tuberculosis appear to do so less readily than the fats and 
proteids. Growing children, however, require more carbohydrates 
than do adults. Malt is especially valuable as a tonic in tuberculo- 
sis, and the diastase aids assimilation of farinaceous foods. 

Great diversity exists among different phthisical patients in the 
power of assimilation of food, and even in individual cases during 
the progress of the disease. 

Bauer says : " One not infrequently sees phthisical patients who 
consume the full hospital diet without any visible ill effects, al- 
though their evening temperature oscillates between 102 and 



TUBERCULOSIS 457 

104 F. With such patients one need feel no anxiety as to the choice 
of foods, provided their nutritive value be the same." 

Rest is important in its relations to digestion, and patients 
should not eat when fatigued. Great benefit is often derived by 
lying down and quietly resting, even without sleeping, for half or 
three quarters of an hour before dinner and supper. It is best to 
take the principal meal in the middle of the day unless there is 
fever at that time or soon after it, in which case a hearty breakfast 
and a light lunch will be better borne. 

If much hectic fever is present, it is desirable to employ the 
intervals when the temperature is low for feeding, and it often hap- 
pens that a hearty meal taken between 7 and 10 a. m. may be better 
digested than at any other time of day. 

Patients should avoid eating more food at any one time than 
they can comfortably digest, and it is often best to give food five 
or six times in twenty-four hours, to avoid overworking the 
stomach. If the digestion is feeble, it is best to give only one 
article of food at a time, or else only such varieties of food as 
require the same length of time for digestion (p. 346), and 
patients often do better when they eat all their animal food at one 
meal and vegetable food at another, having regard to the separate 
action performed by the stomach and intestines upon these dif- 
ferent food classes. If there is stomach catarrh, or if the gastric 
juice is feeble, the quantity of fluid taken with meals should be 
restricted to a minimum, excepting in very advanced cases, in which 
the diet may be necessarily entirely fluid. But half a pint of very hot 
water may be taken with advantage half an hour before each meal, 
to cleanse and stimulate slightly the gastric mucous membrane. 

A. L. Loomis wrote : " When the pressure of food in the stomach 
excites cough, or when paroxysms of coughing have induced vomit- 
ing, the ingestion of food must be delayed until the cough ceases, 
or an appropriate sedative may be employed. In those extreme 
cases where every attempt at eating excites nausea, vomiting, and 
spasmodic coughs, excellent results are attained by artificial feed- 
ing through the soft-rubber stomach tube." 

Meats. — Raw beef is extolled by many physicians, especially 
among the French, as possessing peculiar nutritive and even cura- 
tive value for tuberculosis, and in the popular mind its blood-red 
colour and scarlet juice seem to suggest an intimate connection 
with blood formation. It is true that blood and muscle have great 
similarity of composition. The red wines are erroneously regarded 
by laymen in the same light. It has yet to be demonstrated that raw 
meat possesses any advantage over rare steak or underdone roast 
beef beyond the fact that the scraping and mincing process to which 
it is usually subjected prepares it somewhat better for solution by 
the gastric juice. 



458 DIET IN DISEASE 

Patients will often take scraped raw-meat balls contentedly for 
several days, and then acquire a distaste for them. This may be 
overcome by seasoning with a little aromatic herb, such as thyme, 
parsley, or marjoram. Yeo suggests that when made into small 
balls the meat may be covered with powdered sugar or gum, and 
swallowed with a sip of wine or brandy, or the mouth may be rinsed 
with claret to remove the after-taste. 

Both scraped beef and the various preparations of beef powder, 
beef meal, etc., are useful to re-enforce broths, hot milk, milk 
punch, or light soups of vermicelli, tapioca, etc. According to Pro- 
fessor Chittenden, the nutritive value of lean beef being placed at 
ioo, that of beef peptonoids is 140 and that of Mosquera's beef meal 
is 400. If preferred, from one to five ounces of beef meal may be 
eaten daily, spread like jam upon bread and butter. Insomnia may 
be often prevented by taking on retiring a cup of hot bouillon, clam 
broth, or gruel, with a cracker or two. 

Beef juice, extracted by a small meat press, may be ordered two 
or three times a day. It may be seasoned and drunk like bouillon, 
or eaten as a luncheon upon dry toast, crackers, or boiled rice. 

H. P. Loomis gives the following useful details in regard to 
the preparation of this important food : " To obtain from the meat 
the maximum amount of juice, a meat squeezer is absolutely essen- 
tial. There are a number of good ones in the market, which range 
in price from one to three dollars. The best kind of meat from 
which to squeeze the juice is a thick round steak free from fat. 
This should be seasoned with pepper and salt, broiled over a brisk 
fire, cut in pieces two inches square, and then put into the meat 
squeezer. About eight ounces of juice can be obtained from each 
pound of meat. No further direct heat should be applied to the 
juice, as the albumin would be at once coagulated and the juice 
rendered worse than useless. If the juice becomes cold and it is 
advisable to heat it, this can be best accomplished by placing 
the cup in hot water. Freshly squeezed beef juice is the best 
of the artificial preparations of meat known, and the trouble of 
preparing it is well repaid by the marked improvement in the 
patient." 

It is often desirable to give dilute hydrochloric acid and a little 
pepsin after the ingestion of meat or other animal food unless it 
has been predigested. 

Eggs. — Eggs are not well borne if there is dyspepsia or decided 
gastric catarrh. Otherwise they are nutritious and wholesome. 
They may be given raw, beaten, or very lightly cooked in hot water, 
but never hard boiled. They may also be eaten scrambled or as an 
omelet if lightly made. Egg albumin may be well digested when 
the yolk proves too rich. " A raw egg sucked from the shell will) 
often relieve an irritable condition of the larynx " (H. P. Loomis). 



TUBERCULOSIS 459 

Cereals. — Cereals may be used in the early stage of the disease, 
before the alimentary canal is much disturbed, and such foods as 
corn mush, farina, oatmeal, wheaten grits, or germea may be al- 
lowed with cream. If cream and sugar disagree, they may be eaten 
with lemon juice. 

Fruits. — The succulent fruits are well borne in mild cases, and 
are very wholesome and nutritious. Baked and stewed apples may 
be given with cream. 

Fats and Oils. — Fats and oils are indicated in tubercular disease, 
and especially in pulmonary phthisis, in as large amounts as the 
patient may be able to digest. Crisp fat bacon, butter, cream, 
whole milk, egg yolk, cod-liver oil, and olive oil all furnish desira- 
ble forms of fat when the intestine absorbs them. Russell's emul- 
sion of mixed fats is a very digestible preparation by which to 
administer this class of food. 

While fat is being taken it is well to occasionally observe the 
stools to see that none passes away undigested, and if any one fat 
disagrees and causes dyspepsia its use must be restricted, or tem- 
porarily withheld while another is tried. As a rule, cream butter 
and cod-liver oil will prove the best. If a patient can take one 
quarter pound of butter a day it furnishes about one half of the 
necessary heat units. Fats, well digested, seem in some instances 
to have an almost curative power, so greatly do nutrition and body 
weight improve during their use. 

Cod-liver Oil. — The use of cod-liver oil in phthisis should be 
determined by the condition of the digestive organs and the general 
nutrition of the patient. Wherever the digestion is fairly good, in 
the absence of gastric catarrh, the oil is of great nutritive value, and 
it is usually well borne when properly administered. If there is 
much gastric catarrh, or if the stomach is irritable and nausea is 
easily excited, persistence in the use of the oil will only make mat- 
ters worse. It should be at least temporarily discontinued, though 
in the chronic forms of tuberculosis unaccompanied by fever, in 
which debility and emaciation predominate, cod-liver oil is often 
well tolerated. It is on the whole more satisfactory for children than 
adults, particularly in cases of tuberculosis in which the bones or 
glands are enlarged. 

The presence of diarrhoea is to be regarded as a contraindication 
for the administration of cod-liver oil, but unless it is given in large 
quantities it has very little if any laxative effect upon adults, and it 
may usually be continued in doses of a drachm two or three times 
a day, with no ill effect, and, in fact, by improving the nutri- 
tion it may sometimes benefit diarrhoea. Ringer suggests that 
for this class of patients a teaspoonful or more of the oil given 
at night before sleep may be better borne than at any other time 
in the day. 



460 DIET IN DISEASE 

Commonly it is best to give the oil pure and uncombined if it 
can be tolerated. It may be given in capsules, although they are 
not always dissolved at the proper time in the stomach. Patients 
who require alcohol may take the oil in whisky. For the many dif- 
ferent methods of administering it and of disguising its taste the 
reader is referred to the section on Cod-liver Oil (p. 201). The 
isolated active principle of the oil, called gaduin, has been employed 
with some degree of success (p. 200). 

Alcohol. — Alcohol is not believed to possess any specific action 
in phthisis, and in many cases it is positively harmful. As a rule, if 
patients have a fair appetite and are improving in strength its use 
is contraindicated. When alcohol is required as a food and tonic 
rather than as a stimulant, the best form in which to give it is that 
of malt liquor or light wine. One or two pints daily may be pre- 
scribed of beer, stout, or porter, or half a pint of claret or sound 
Burgundy is useful if anaemia is marked. The light Hungarian, 
Italian, or Greek wines may be used by those whose purse places 
them within reach. One of the Tokay wines, with cocoa, may be 
prescribed. Sweet wines, sherry, port, Madeira, and champagne 
are not as useful. They are liable to disagree and cause dyspepsia 
and headache. 

The promiscuous habit of daily drinking rum, whisky, or other 
strong liquors in tuberculosis is to be condemned. 

No class of patients exhibits more painfully and rapidly the in- 
roads of the disease than those who for a long time have been hard- 
ening their own tissues, like pathological specimens, with daily 
draughts of strong alcohol. The cirrhotic changes which occur in 
various organs are the best possible preparation for the advance- 
ment of tubercular processes. If the exhibition of alcohol increases 
the temperature and the pulse rate, and is followed immediately by 
greater weakness, it is doing harm. Advanced cases of tubercu- 
losis show great toleration for alcohol, but it does not follow that 
it is proportionately benefiting them. When in the course of an 
ordinary case the hectic fever becomes high and exhausting, the 
pulse feeble and rapid, and the digestion fails, it may be best to 
lessen the quantity of food and give more stimulation. Usually 
three or four, but seldom more than six, ounces of whisky, brandy, 
or rum may be required daily for this purpose. Special pains should 
be taken to use only such liquors as are strictly pure and of the best 
quality. 

Diet in Mild Cases 

The following liberal menu will furnish abundant variety from 
which to select the dietary for tubercular patients in whom the 
progress of active lesions is in abeyance or completely arrested, 
and in whom there is little or no gastric catarrh. Patients should 



TUBERCULOSIS 46 1 

eat all they can digest, especially of milk, eggs, and butter, and 
should allow five hours' interval between meals. 



FOODS ALLOWED IN NON-ACTIVE CASES WITHOUT GASTRIC 

CATARRH 

Soups and broths : Mutton, oyster, clam, barley, vermicelli, bou- 
illon, chicken with rice. 

Purees of peas, beans, tomatoes, celery. It is often well to add 
to them meat extracts, peptonoids, beef meal, etc. 

Milk or cream in any form, including buttermilk and koumiss, 
clotted or Devonshire cream, whipped cream, etc. 

Shellfish : Oysters or clams, either raw, roasted, or broiled (the 
livers or " soft parts " only). 

Fish of any kind if fresh, either boiled or broiled (never fried), 
sardines (if they " agree ") for the sake of the oil. 

Eggs, preferably raw or very lightly cooked, or in eggnog or cus- 
tard, also poached, scrambled, or in plain omelet (never hard-boiled). 

Meats : Beefsteak, rare roast beef, scraped-beef sandwiches or 
meat balls, lamb or mutton, roasted or boiled; chops; chicken, 
capon, turkey, either roasted, boiled, or broiled. 

Game : Partridge, squab, woodcock, snipe, prairie chicken, quail, 
roasted or broiled. 

Meats, especially beef and mutton, should predominate. Gelatin 
may be used, but it is not very nutritious. It should be combined 
with meal or meat preparations. 

Entrees: Sweetbreads. 

Fats and oils (as much as can be digested) : Good fresh butter, 
olive oil on lettuce or raw tomatoes, cod-liver oil, the fat of beef or 
mutton (if it " agrees "), cream (on everything with which it can 
be appropriately eaten), a little fat bacon. Pancreatin or pancreatic 
emulsions will aid the digestibility of fats. 

Vegetables : Baked potatoes, tomatoes stewed or raw, very 
young green peas, string beans, spinach, celery (stewed), onions, 
boiled asparagus, lettuce, cauliflower. 

All vegetables to be eaten in moderation. 

Cereals : Whole-meal bread, wheaten or rye, only if stale or 
toasted, zwieback, rusk, milk-toast, cream-toast, crackers, malted 
bread and biscuit, rice in any form, mush, hominy, farina, cracked 
wheat, wheaten grits, oatmeal, macaroni, spaghetti. 

Some authors recommend lentil flour, on the ground that it 
contains both iron and phosphorus. Oatmeal contains considerable 
fatty matter, and maize has still more. All cereals are to be eaten 
sparingly. 

Fruits : Apples, baked or stewed, oranges, shaddock, grapes, 
pears, peaches, plums, strawberries, blackberries, olives. 



462 DIET IN DISEASE 

Desserts: Wine jelly, custard, blancmange, rice pudding, bread 
pudding, junket and cream, Bavarian cream. 

Avoid fried foods, rich sauces, pastry, cakes, hot breads, ra- 
gouts, beans, carrots, turnips, cabbage, confectionery, puddings, 
dried foods, salt fish or meats (except as specified above). 

Beverages Allowed. — Water, tea, coffee, cocoa, milk, koumiss, 
zoolak, buttermilk, milk punch, lemonade or orangeade, Vichy or 
other aerated water, non-fermented grape juice, malt extracts. 

Alcohol : Beer, ale, porter, wines, liquors, are permissible only 
if needful for special symptoms — that is, if desirable for food or to 
aid digestion and promote exercise. 

H. P. Loomis gives the following useful sample diet, with the 
appropriate intervals for taking food. A glass or two of milk may 
be added at night with advantage : 

" On Awakening. — Eight ounces of equal parts of hot milk and 
Seltzer, taken slowly through half an hour. 

" Breakfast. — Oatmeal or cracked wheat, with a little sugar and 
an abundance of cream, rare steak, or loin chops with fat; soft- 
boiled or poached egg, cream-toast, half pint of milk, small cup of 
coffee. 

" Lunch, 10 a. m. — Half pint of milk or small teacup of squeezed 
beef juice, with stale bread. 12, noon : Rest or sleep. 

" Midday Meal, 12.30. — Fish, broiled or stewed chicken, scraped- 
meat ball, stale bread, and plenty of butter, baked apples and cream, 
two glasses of milk. 

" Lunch, 4 p. m. — A bottle of koumiss, raw scraped-beef sand- 
wich, or goblet of milk. 5.30 p. m. : Rest or sleep. 

" Dinner, 6 p. m. — Substantial meat or fish soup, rare roast beef 
or mutton, game, a slice of stale bread, spinach, cauliflower, or other 
fresh vegetables in season (sparingly)." 

At 9 p. m. half an ounce of cod-liver oil should be taken, or an 
ounce of peptonised cod-liver oil and milk. At 2 a. m., or there- 
about, if the patient awakens, a glass of milk, zoolak, or diluted 
cream should be drunk, or a scraped-beef sandwich may be eaten. 

Diet in Advanced Cases 

It not rarely happens that patients who have suffered much 
from indigestion in the earlier stages of phthisis finally reach a 
condition in which, although greatly emaciated and prostrated, they 
seem able to eat and digest a much larger variety and quantity of 
food than before. As these cases are utterly hopeless, it is often best 
to let such patients select their own diet, providing only that it is 
nutritious and of a quality which does not excite cough or diarrhoea. 

If the bowels are not too loose, fresh fruit, especially oranges, 
may be allowed, and proves very refreshing. 



TUBERCULOSIS 463 

In very advanced cases, and in all cases during acute exacerba- 
tions of severity, with marked prostration, the patient must have 
food every two or three hours, and the intervals of feeding should 
never be longer than the latter. A diet consisting very largely of 
milk or milk and cream is best, but broths and pancreatinised meat 
preparations, albumoses, and tgg albumin may be added. 

Milk Diet. — Milk is a food which is especially adapted for con- 
sumptives, many of whom do best when living upon it almost ex- 
clusively, while others should drink it freely in connection with 
other nourishment. It is fattening, is assimilated without over- 
taxing the digestive organs, and taken hot, either alone or with an 
equal part of Vichy, it is soothing to the throat and ameliorates 
the cough. 

Advanced cases of tuberculosis living upon full milk diet should 
take between two and a half and four quarts a day, but not over 
eight ounces at once. It should be sipped, or really eaten, and not 
drunk, for it then will coagulate by slow degrees in the stomach 
and not form large indigestible curds. This should be insisted 
upon and ten minutes should be occupied in drinking half a pint. 
If the milk disagrees at first it may be modified in any one of the 
ways suggested on p. 74, but it is best not to give it in connection 
with beef juice. 

In this country cow's milk is preferred, but elsewhere the milk 
of other animals serves equally well. Goat's milk, drunk largely in 
Switzerland, contains more salts of lime and is good for cases of 
tubercular diarrhoea, and sometimes ass's or mare's milk proves 
more digestible. The latter varieties are principally used in Russia. 

Lebert's Milk Cure (from Bauer). — " Lebert directs the patient 
to drink slowly three hundred to five hundred grammes of milk 
every morning and evening between five and six o'clock, fasting. 
He prefers it freshly drawn from the cow, and if, in consequence of 
having stood for some time, a separation of the cream has already 
begun, recommends it to be skimmed off. 

" During the continuance of the milk treatment the patient is 
allowed a substantial dinner, at least of soup, roast meat, young 
vegetables, stewed fruit, etc., and a little beer or wine. At the dis- 
cretion of the physician a proper breakfast may be taken an hour 
after the morning's milk of a cup of tea with plenty of milk and 
biscuits and, perhaps, one or two light-boiled eggs, and again in 
the evening a good soup, as well as, when possible (i. e,, in the 
case of non-febrile patients), some more roast meat. If milk is 
well borne, the regular breakfast and supper may be supplemented 
by further doses of one hundred to two hundred grammes of 
milk." 

Whey or koumiss may be drunk instead of milk. For those 
who can digest it, cream is an excellent food. With some patients 



464 DIET IN DISEASE 

cream diluted with an equal bulk of hot water agrees even better 
than milk. The taste, if complained of, may be modified by a very 
little tea or coffee, or salt or sugar. Yeo sometimes adds a tea- 
spoonful of rum or brandy or aromatic spirits of ammonia. Some 
patients can take a quart of cream besides a quart and a half of milk 
per diem with profit. 

SURALIMENTATION 

Suralimentation, called also " superalimentation," or " forced 
feeding," is based upon the theory that the best method to com- 
bat the symptoms of phthisis is by " stuffing " the patient with all 
the food which he can possibly digest. More food is needed than 
in health to counterbalance rapid tissue waste. The appetite is not 
always a reliable indication of the strength of the digestive organs, 
and, acting upon this fact, Debove introduced the plan of feeding 
by means of the oesophageal tube. It is only necessary to use this 
method when a patient loses all appetite, or acquires a positive dis- 
gust for food, and rapidly emaciates in consequence. The tube is 
employed in the manner described for feeding cases of insanity, and 
any form of desirable fluid food is introduced through it. It is 
sometimes only necessary to pass the tube to the level of the 
oesophagus, and the first few times that it is used it may be well 
to brush the pharynx with a two-per-cent solution of cocaine. The 
meals may be given three or four times a day, or a patient whose 
appetite is not wholly lost, but is inadequate, may prefer to eat 
part of his food himself and have other meals furnished through 
the tube. 

The following are the foods most suitable for tube feeding: 
1. Milk and its preparations; cream. 2. Raw eggs, eggnog. 3. 
Meat extracts, beef meal or powder. 4. Leguminous purees and 
cereals, thoroughly cooked and made fluid by predigestion with 
malt extract. A quart may be given at a time. If gastric catarrh 
is present the gavage should be preceded by lavage. 

Debove, speaking of his method, says : " A patient who has no 
appetite, or who has a decided disgust for all food, will digest per- 
fectly a large meal introduced by the tube, and even at the end of 
a certain time will recover appetite." 

His method is first to wash out the stomach with cold water, 
and then pour in through the tube a litre of milk, one hundred 
grammes of fine meat powder, and an egg. 

He adds that with suralimentation night sweats, cough, and ex- 
pectoration are all reduced or disappear completely, while there is 
considerable gain in weight and strength and improvement in the 
physical signs in the chest. 

Suralimentation may also be conducted without the stomach 
tube in patients who are able and willing to eat. They may be 



TUBERCULOSIS 465 

given five or six meals a day. This applies to patients who are 
not having severe hectic fever, and in whom gastric catarrh is not a 
prominent symptom. Should vomiting occur during the treatment, 
it will be necessary to suspend it until the stomach is again in 
order. As a rule, in such instances it is better to discontinue medi- 
cines than food, if both are being taken. The presence of moderate 
fever — one or two degrees — is not in itself alone a contraindica- 
tion for forced feeding, or for keeping the patient confined to bed. 
The gain of appetite which often accompanies removal to a favour- 
able climate may be utilised to promote forced feeding. 

The following diet recommended by Solis-Cohen serves as a 
good illustration of the proper regimen in the cases under discus- 
sion : 

"Diet for Forced Feeding 

" The patient is to take a pint of hot water in the early morning 
to stimulate the stomach and cleanse it of mucus accumulated over- 
night. 

" A half hour after the morning bath, milk punch and beef meal 
or peptonoids. 

" Breakfast, a half hour later, consisting of rare steak or chop, 
eggs, sliced tomatoes, bread with plenty of butter, or cracked wheat 
and cream. In two hours, koumiss or soup, milk, bread and but- 
ter, celery salad, broth, and peptonoids. 

" Dinner, 1 p. m. — Bouillon, rare beef, greens, Burgundy, beer, 
fruits. 

" 3 or 4 p. m. — Koumiss, cream, or milk punch, peptonoids, malt 
extract. 

" 7 p. m. — Supper, like breakfast. 

" 9 or 10 p. m. — Cream and cocoa or coca wine, milk, and pep- 
tonoids." 

The patient should keep milk, or peptonoids, or some nutritious 
beverage by the bedside to be drunk if he awakens in the middle 
of the night. 

Another diet well suited to some patients is thus outlined by 
Weber in his Croonian Lectures : 

" 7 a. m. — While still in bed, a cup of milk with a dessertspoon- 
ful of Cognac or lime water, or a cup of tea or cocoa, with bread 
and butter. 

" 8.30 to 9 a. m. — After dressing, milk and tea or coffee, bread 
and butter, fish, ham, or bacon. 

"11 a. m. — Milk, koumiss, or broth, or a sandwich and glass of 
wine. 

" 1 to 1.30 p. m. — A substantial meal of meat, poultry, fish 
or game, fresh vegetables, a light pudding, fruit and a glass 
of wine. 



466 DIET IN DISEASE 

" 4 p. m. — Milk or koumiss, tea or coffee, with bread and but- 
ter or biscuit. 

" 7 p. M. — Another meal like that at I p. m. 

" 9.30 to 10 p. m. — A cup of milk, bread and milk, or milk or 
cream and farinaceous food, such as Hart's, Liebig's, Nestle's, or 
Mellin's. A glass of brandy if there are night sweats." 

The question may properly be asked whether it is not possible, 
to overfeed patients in this manner? This will happen when the 
increase in body weight exceeds the breathing capacity of the lungs 
— in other words, when the facilities for oxygen supply are dispro- 
portionate to the bulk of tissue to be supplied. The symptoms will 
be a coated tongue with dyspepsia and biliousness, increased pulse 
frequence, and possibly increased dyspnoea on exertion, all occur- 
ring without aggravation of the local physical signs. The food 
must then be reduced in amount. Both fluids and solids are to be 
restricted, and fish may replace meat temporarily. 

Aids to Dietetic Treatment 

It is not within the scope of this work to discuss the details of 
hygiene, but they should be at least mentioned as important ad- 
juncts to dietetic treatment. In those cases especially in which 
forced feeding is recommended it is desirable to promote oxidation 
in every way. Patients should live in the open air all they can, 
sleep with the windows open, and, if possible, should go to a 
climate which enables them to be outdoors all day long. They 
should wear flannel undergarments, but should avoid dressing too 
warmly, and keep the feet warm and dry. Habits of moderate exer- 
cise, instruction in proper methods of breathing, cold bathing, mas- 
sage, and reasonable mental diversion and good cheer are all useful 
factors in improving the digestion and assimilation of food. Worry 
and nervous strain of every kind should be avoided. Nine hours 
should be nightly allotted for sleep. 

Of the long list of medicinal remedies which have from time to 
time won favour or notoriety for the treatment of tuberculosis, 
those which have best withstood the test of practical experience 
are the ones which, like creosote, act mainly by maintaining asepsis 
and preventing malfermentation in the alimentary canal. It is im- 
material whether cod-liver oil be considered as a medicine or as a 
food. It has already been discussed as a food. In a negative 
way it should be stated that one of the best aids to digestion con- 
sists in preventing the patient from disordering the stomach and 
the appetite with all manner of cough mixtures and ill-advised 
tonics. 

Such medicines as may from time to time be required for emer- 
gencies will be much better absorbed if the stomach has not been 



THE RESPIRATORY SYSTEM 467 

long kept in a state of dyspeptic irritability. In patients with con- 
stipation appetite and digestion will be improved by catharsis. 

Diet " Cures" for Phthisis 

Many special forms of dietetic treatment have been devised and 
extensively practised for the cure of pulmonary tuberculosis. The 
details of these " cures " are elsewhere described. The principal ones 
are the "Milk Cure" (p. 719), the " Whey Cure" (p. 721), the 
" Koumiss Cure " (p. 82), practised chiefly in the steppes of south- 
eastern Russia, and the " Grape Cure " (p. 724), conducted at Me- 
ran, Montreux, and elsewhere in the months of September and 
October. Aside from climatic influences and the effects of good 
hygienic surroundings, their benefits are attributable only to the 
fact that the patient is encouraged to take a large quantity of 
easily digestible food and live constantly in the open air. Patients 
with chronic phthisis are notoriously sanguine as to the possibilities 
of their ultimate recovery, and it is also true that their mental state 
reacts to a greater degree upon their physical condition than in 
almost any other disease. 

All manner of absurd foods, such as fish roes in Germany and 
snails in the south of France, have achieved fame with credulous 
persons as possessing specific virtues in the cure of phthisis. It 
should be as much the duty of the physician to protect them from 
the chagrin, disappointments, and expense of following dietetic illu- 
sions as to encourage them in every reasonable effort for improve- 
ment. Beyond the requirements of a good, nourishing, easily diges- 
tible diet, there is no specific food " cure " for tuberculosis, as there 
is no medicinal cure. 



DIET IN DISEASES OF THE RESPIRATORY SYSTEM 

Laryngismus Stridulus 

• In children who are subject to spasmodic croup the attacks are 
often precipitated by dyspepsia caused by overfeeding and nurs- 
ing, by improper food, or by constipation. The diet must therefore 
be regulated according to the rules laid down under the heading 
Infant Feeding. The habit of night feeding especially should be 
much restricted after the first month of life. This can usually be done 
after two or three trials. If the infant awakens crying" at night it 
must be offered a little cool water, and it may presently drop 
asleep. Up to the fourth month six meals a day, three hours apart, 
are all that are allowed, and from that time on until the second 
year five meals must suffice. 

Between the attacks the milk should be lessened in amount, and 



468 DIET IN DISEASE 

so modified as to insure more perfect digestion. Children over six 
months of age should be given from one to three tablespoonfuls of 
pressed beef juice in a day. 

Older children had better be kept upon a fluid diet of meat 
broths, milk, and egg albumin, solid food being withheld until the 
seizures abate. Cod-liver oil should be given in most cases. 

Tubercular Laryngitis 

In tubercular laryngitis intense pain is excited by the act of 
deglutition. Nutritious but non-irritating food is therefore required. 
Thick soups and gruels, purees, cream, beaten raw eggs, scraped 
rare beef, raw oysters, junket, can all be swallowed more readily 
than very fluid or solid food. Strong condiments, vinegar, and salt 
must be avoided, for they increase the pain. 

The difficulty experienced in deglutition is considerably relieved 
by the method proposed by Wolfenden, which is to have the patient 
lie prone on a lounge, and with his face protruding over the lower 
edge he is to suck through a glass tube semifluid food from a tum- 
bler on the floor. Sajous advises the patient to lean over forward 
when eating, which, he says, " causes the food to pass down along 
the pyriform sinuses, thus avoiding the upper portion of the larynx, 
contact with which causes the severe pain experienced by advanced 
cases during the act of deglutition." 

HEMORRHAGE OF THE LUNGS 

Haemorrhage of the lungs, or rather from the bronchial mucous 
membrane, when occurring suddenly and in considerable amount, 
greatly reduces the strength, and naturally alarms the patient and 
excites the nervous system. Absolute quiet must be immediately 
secured by rest in bed without a pillow, so that the body may lie 
flat, and the head and arms should on no account be raised. The 
room should be kept quiet and the patient must not be allowed to 
speak or to feed himself. A reliable and quiet nurse should be 
secured for him, and he should be fed upon a nutritious diet, which 
requires no effort in eating. Small quantities only of fluid should 
be given at one time through a glass tube or by a teaspoon, so that 
the head need not be raised. If nausea occurs, every effort must 
be made to control it, for the violent muscular action and the tem- 
porary circulatory and respiratory disturbances occasioned by the 
act of vomiting might excite further haemorrhage. It is desirable 
to reduce the blood pressure in the lungs as much as possible in 
order to allow coagulation of the blood to occur over the oozing 
surface of the bronchial mucous membrane, and therefore large 
quantities of fluid should not be given at first. The patient is usu- 



THE RESPIRATORY SYSTEM 469 

ally thirsty from the loss of blood and temporary drying of secre- 
tions. The thirst may be relieved by crushed ice and small quan- 
tities of cold acidulated drinks, such as very dilute phosphoric acid 
or sour lemonade, and if the stomach is in normal condition, plain 
milk may be given or else pancreatinised milk and strong beef 
broth in quantities not exceeding two or three ounces in as many 
hours. 

It is customary to administer all fluids cold, but the advantage 
of this is overrated. Warm fluids have a somewhat more stimulat- 
ing effect upon the heart, and are more rapidly absorbed, but the 
idea sometimes advanced that the cold of iced fluids taken into the 
stomach is ever sufficient to constrict the bleeding bronchial ves- 
sels, even by supposed reflex action, does not appear rational. For 
a full discussion of this question the reader is referred to experi- 
ments reported upon p. 333. 

If coincident gastric disorder is present with bronchial haemor- 
rhage, to forestall vomiting it may be better to resort to nutrient 
enemata. 

In cases where exceptionally large quantities of blood have been 
lost, the blood pressure may be greatly reduced and the danger of 
death from heart failure may appear imminent. It then becomes 
necessary to give a larger quantity of fluid, and the rules in regard 
to the dietetic treatment of severe and sudden haemorrhage taking 
place anywhere from the body must be observed. Salt and water, 
a teaspoonful to the pint, may be injected into the rectum, or even 
beneath the skin. Most cases, however, are more mild, and after a 
few hours of rest and quiet, furthered, perhaps, by the hypodermic 
injection of morphine, the patient will be able to retain a little sim- 
ple semisolid food, such as milk toast, a beaten egg, junket, etc. 

If there is no return of the haemorrhage in a day or two, the 
diet should be increased and anaemia consequent upon the bleeding 
must be treated by an abundant meat diet. As a rule, alcoholic 
stimulants should be avoided, on account of the relation of blood 
pressure to the bleeding, or they should be given in moderation, 
unless the danger of heart failure is imminent. 

Acute Capillary Bronchitis 

In acute capillary bronchitis in infants and children a wholly 
fluid diet of the simplest but most nutritious kind must be enforced. 
In young infants milk alone, in older children milk, meat juice, 
meat broths, and beaten eggs or egg albumin, should be fed at 
least every two hours in such quantities as the stomach will bear. 
It may be best to pancreatinise all food. Very feeble children will 
require food oftener, and sometimes a teaspoonful only should be 
ordered once every fifteen or twenty minutes. If the child refuses 



470 DIET IN DISEASE 

food or vomits constantly, nutrient enemata (p. 408) must be pre- 
scribed once in three or four hours. 



Chronic Bronchitis 

The diet for chronic bronchitis is substantially the same as that 
recommended for the earlier stages of pulmonary phthisis, to which 
the reader is referred (p. 455). 

The cough is often momentarily relieved by drinking hot lemon- 
ade, hot milk and Seltzer or Vichy, glycerin and whisky, and some- 
times by sucking a raw Qgg through the perforated shell. 

Asthma 

Spasmodic bronchial asthma is believed to be occasioned by 
temporary spasm of the bronchial muscles which narrows the lumen 
of the tubules and obstructs the free entrance and exit of air. It is 
also attributed to hyperemia and swelling of the bronchial mucous 
membrane, and possibly, in some cases, to a reflex spasm of the 
diaphragm and other muscles of inspiration. Asthmatic patients 
soon find from experience that errors in diet are liable to precipitate 
an attack, and overloading the stomach or eating particular kinds 
of food, which are unwholesome or against which the individual 
possesses some idiosyncrasy, may excite dyspnoea. Aitkin showed 
a true appreciation of the importance of diet in this disease when 
he wrote : " More is to be done for asthmatic patients on the side 
of the stomach than in any other direction," and " the asthmatic 
can never with impunity eat and drink as other people." 

Accumulation of large quantities of undigested and fermenting 
food results in the production of gas in both the stomach and intes- 
tines, which become distended and by pressure interfere with the 
movements of the diaphragm and abdominal muscles in free respira- 
tion. The chemical irritation of undigested food may be a cause 
of reflex spasm of various muscles, and may possibly affect those 
of respiration. It is therefore necessary for asthmatics to exercise 
care in the selection of their food and to keep the digestive organs 
in as normal a condition as possible. All food which is constipating 
or which is liable through fermentation to evolve large quantities of 
gas should be shunned. In general, fats and sweets should be 
given up, and starchy food, if eaten at all, must be very thoroughly 
cooked and slowly masticated, in order that the salivary digestion 
of it may be as complete as possible. Pork, veal, and cheese must 
never be eaten, and elaborate cooking and desserts are forbidden. 
No water should be allowed with meals or until at least three hours 
thereafter. A cup of very hot water may be drunk an hour before 
each meal and again at night. 



THE RESPIRATORY SYSTEM 471 

In most persons the asthmatic attacks are worse at night, and 
in many they only occur at that time. It is consequently better 
for them to take the principal meal of the day at noon and to eat a 
light supper, so that gastric digestion may be finished before going 
to bed. 

The following diet may be offered as giving a general idea of 
the regimen for somewhat advanced cases : 

Breakfast. — Bread and milk or well-cooked oatmeal porridge or 
wheaten grits without sugar (lemon juice may be added instead). 
A chop or a little broiled fresh fish, coffee without sugar. 

Dinner (not later than 2 p. m.). — Beef or mutton, bread, one or 
two green or succulent vegetables, such as spinach, stewed celery, 
stewed or raw tomatoes. Blancmange or custard (not sweetened), 
or a little rice pudding. Fresh fruit in season, such as a peach or 
baked apple. 

Supper (6 p. m.) — A soft-cooked &gg or a little cold fowl or 
game, stale bread, toast, or zwieback, milk, stewed fruit (without 
sugar). 

Patients should eat very moderately, masticate thoroughly, and 
take their meals with punctuality. 

Among beverages, coffee without sugar is better borne than 
tea. Loomis believed that " not infrequently a paroxysm of asthma 
can be warded off by taking two or three cups of strong coffee im- 
mediately upon the accession of the first asthmatic symptom." 

During an attack non-alcoholic patients may take a hot strong 
lemonade with whisky or a hot brandy and soda. Malt liquors are 
forbidden. 

Emphysema 

Patients suffering from emphysema have more or less engorge- 
ment of the venous circulation, and hence are liable to catarrh of 
the stomach and intestines. The dyspnoea from which they suffer 
on exertion is considerably aggravated by flatulency, and their diet 
must be regulated to prevent this occurrence. In general, starchy 
and saccharine foods are to be avoided, as constipation must be 
prevented. For a discussion of these principles, the reader is re- 
ferred to the articles upon Gastric Dyspepsia and Constipation. 

The patient must be particularly warned against too rapid eating 
and overeating. Condiments, sauces, fried and greasy food, and 
all obviously indigestible articles, must be shunned. Fluids should 
not be taken with solid food, and should be used in moderation. 
Water may be drunk an hour before meals, but not for three hours 
after. In the early stages a nourishing diet, consisting chiefly of 
animal food, meat, fish, milk, cream, eggs, and good butter, should 
be taken. If dyspnoea predominates with frequent asthmatic at- 
tacks, it will be best to substitute milk largely for other foods, and 
32 



472 DIET IN DISEASE 

in the later stages, with a feeble heart and increasing congestion of 
the abdominal viscera, the diet should consist solely of milk and 
meat broths. Cod-liver oil is an excellent food in emphysema. 

Pneumonia 

Symptoms. — Pneumonia is an infectious inflammatory disease of 
the lungs, accompanied by grave constitutional disturbances, such 
as fever and rapid and enfeebled heart action. The mortality at 
some seasons of the year, and especially among debilitated or alco- 
holic patients, is very great, and since no known remedy can limit 
the disease, it is exceedingly important to maintain the strength of 
the patient through the few days during which the fever lasts, or 
until the crisis by which it terminates has been reached. All danger, 
however, is not then over, and convalescence in all cases, and espe- 
cially in aged persons, must be promoted by careful dietetic treat- 
ment. The onset of the disease is acute, and the fever is often 
high, reaching 104 or 105 or more on the first day. The duration 
of the fever varies from five to seven or nine days on the average, 
when it subsides by a sudden fall. The rate of respiration is greatly 
accelerated, with or without subjective dyspnoea. More or less 
cough accompanies the fever, and there is frequently delirium. 

Dietetic Treatment. — The indications for treatment are to give 
a light diet, which will not excite the cough in swallowing or in- 
crease dyspnoea by distention of the stomach, or augment the en- 
feeblement of the heart action by overtaxing the digestive powers. 
Vomiting should be especially guarded against, and if nausea exists, 
efforts should be made at once to control it. It is not necessary to 
keep the patient upon a rigid milk diet, but if milk is well borne, it 
is advisable to give nothing else while the acute symptoms last ; 
otherwise, whey, meat juice, broths, and egg albumin may be 
allowed. Starchy and saccharine food must be withheld. Cold 
drinks are both acceptable and beneficial to the patient, and water, 
plain or aerated, such as Apollinaris or soda water, may be drunk in 
considerable quantity. It is believed by some authorities that the 
activity of the kidneys may be thus promoted, and that the poisOn 
which occasions the constitutional symptoms of the disease may be 
better eliminated. There are cases, however, among persons with 
robust circulation in which the onset is very sudden and violent. 
The pulse is full and bounding, and the heart is greatly overworked 
by the effort to propel a large volume of imperfectly aerated blood. 
In such instances the addition of large quantities of fluid to the cir- 
culation, besides what is actually required for nutrition, may have 
the effect of still further straining the heart. 

It is stated that carbonated waters reduce the viscidity of the 
sputum, which is often very tenacious. 



THE RESPIRATORY SYSTEM 473 

The diet should be kept fluid until defervescence has occurred, 
with a normal temperature and commencing disappearance of the 
exudation — in fact, it is well to prolong the fluid diet tor three or 
four days after the temperature has become normal, in order to 
make sure that a relapse of the fever is not likely to follow. In 
those cases in which resolution is postponed and the patient be- 
comes more and more feeble, although the temperature may be 
nearly or quite normal, it may be desirable to give a little properly 
prepared solid food somewhat earlier, and scraped beef, milk toast, 
or a soft cooked tgg may be added to the milk diet. 

During the entire period of convalescence the diet must be very 
nourishing and of easy digestion ; milk may still be given, and after 
slowly returning to the regulation three meals a day (see Convales- 
cent Diet, p. 435) patients do well to take milk punch, or egg- 
nog, or a glass of wine and a biscuit three or four times a day in 
the intervals. 

Alcohol is exceptionally well borne, and it undoubtedly serves 
both as a food and as a support to the overworked heart. The fact 
that it is thoroughly oxidised in the circulation or tissues is dem- 
onstrated by the large quantities which patients can often digest 
and absorb without toxic symptoms. Doses may be thus tolerated 
which in health would ordinarily produce drunkenness. In alco- 
holic subjects who have been drinking up to the time of the onset 
of the disease it is indispensable to continue the use of alcohol, for 
the sudden withdrawal of its stimulating effect on the organism may 
give rise to rapid collapse. In aged and constitutionally weak per- 
sons it is also important that its use should be begun early in con- 
siderable quantities. 

In extreme cases as much as an ounce every two hours, or twelve 
ounces in the day, may be given with benefit, but ordinarily from 
six to eight ounces will suffice. There are other cases found among 
robust subjects who do not need such stimulation, and possibly may 
not require alcohol at all. The custom now in vogue of prescribing 
other forms of cardiac stimulants, such as strychnine, and vaso- 
dilators, like nitroglycerin, makes the employment of excessive 
doses of alcohol less imperative. It should always be remembered 
that it is undesirable to produce toxic symptoms of alcoholism in 
pneumonia as well as in any other disease. So long as the pulse is 
slowed and its force strengthened the use of alcohol may be re- 
garded as beneficial ; but if delirium is increased and the odour of 
whisky or brandy is strong in the breath an hour or two after it 
has been given, it is an indication that the patient is receiving 
more than is desirable, and the dosage should be reduced. From 
its serving as a fuel, and thereby saving tissue waste in the 
muscles, the free use of alcohol in pneumonia undoubtedly saves 
many lives. 



4/4 DIET IN DISEASE 



Broncho- Pneumonia 

Symptoms. — Broncho-pneumonia is common at the extremes of 
age, in the very old and very young. The mortality is greatest in 
children under two years of age. It is the sequel to many of the 
acute diseases of childhood, and is also produced by the tubercle 
bacillus and by the inspiration of particles of food or fluid which are 
drawn through the larynx to the bronchi by inhalation during the 
act of swallowing. The latter variety may occur as a result of draw- 
ing seeds or other hard substances into the bronchi ; from operations 
about the mouth and upper air passages after tracheotomy ; and from 
the conditions which impair the normal sensitiveness of the larynx 
and the reflex action of the epiglottis and vocal cords, such as pro- 
found uraemia or apoplectic or alcoholic coma, and post-diphtheritic 
or laryngeal paralysis. A few cases have been produced by careless- 
ness in the passing of the oesophageal catheter into the larynx and 
pouring liquid food into it. 

Dietetic Treatment. — Broncho-pneumonia is always a very crit- 
ical disease and the utmost care is required in nursing and feeding. 
The diet should consist of such articles as meat juice, predigested 
milk, and egg albumin. Stimulation is early required and in con- 
siderable quantity. Brandy or whisky sweetened with a little sugar 
and cold water should be systematically given, especially to young 
children, who are unable to make their want of drink known. Hot 
milk and Vichy, in the proportion of one part of Vichy to two of 
milk for older children, or half-and-half for young infants, may 
have the effect of loosening the tenacious mucus and easing the 
cough. If there is any tendency to flatulency, aerated waters had 
better be avoided. 

When the disease occurs in children the diet should be adapted to 
foster the strength and tax the digestive organs as little as possible. 
At first food should be given every two hours, and milk is usually 
all that is required. Later it may be alternated with or supple- 
mented by egg albumin, expressed meat juice, plain beef or mut- 
ton broths, arrowroot, or other gruels. 



Pleurisy 

Of the various forms of pleurisy, those which are chiefly influ- 
enced by diet are pleurisy with effusion and empyema. In pleurisy 
with effusion the objects to be attained are to preserve the strength 
of the patient and promote the reabsorption of the fluid in the pleu- 
ral sac. A diet is therefore advised which shall consist of nutritious 
solids with a minimum amount of fluid, in order that the blood may 
become more dense and that favourable osmosis may occur from 



THE RESPIRATORY SYSTEM 475 

the pleuritic cavity into the blood vessels ; at the same time free 
action of the kidneys should be promoted. To still further favour 
the absorption of fluid, a special dry diet has been recommended in 
which, as in case of aneurism, the patient is encouraged to take as 
little fluid as possible and to eat table salt by the teaspoonful, the idea 
being to increase the density of the blood both by withholding fluid 
and adding salt, and that the latter may also promote osmosis. This 
treatment has been attempted in several of the New York hospitals 
and elsewhere, but has not met with success, mainly, no doubt, on 
account of the difficulty of overcoming the thirst of the patient, 
which is doubly aggravated by the lack of fluid and the supply 
of salt. 

An extreme dry diet known in Germany as " Schroth's Method " 
has been indorsed by Niemeyer, Pimser, and others. The patient 
is fed upon lean roast veal and stale rolls {Butterbrod) without 
fluid of any kind but a little water until the third day, when half a 
pint of red wine is given. At the end of a week a pint is allowed. 
Very few patients will submit to such treatment in this country, and 
it certainly is severe. A reasonable abstinence from fluids, espe- 
cially water, is all that can be expected. Practically, many patients 
are found to go on reabsorbing pleuritic exudation while continuing 
a milk or other fluid diet which is necessitated by some complica- 
tion in the digestive system. 

Several French writers, as Serre and Eloy, advocate an exclusive 
milk diet, giving from three pints to three quarts daily, to be sipped 
in small quantities every hour or two. They rely upon the diuretic 
effect of the milk, and give it in any form most agreeable to the 
patient. The treatment is continued for a week or more after the 
exudation has been absorbed, and return to a solid diet must be 
gradual. 

This method is obviously directly opposed to the dry diet, and 
possesses no advantages over it, excepting sometimes in cases com- 
plicated by chronic valvular heart disease, gastric catarrh, or ad- 
vanced anaemia. In England and Europe thoracentesis appears to 
be much less practised than in this country, whefe it is performed 
with but little hesitation. 

If the pleuritic exudation accumulates in sufficient quantity to 
severely embarrass respiration or the action of the heart, it is so 
easy to absolutely withdraw it by the aspiration needle when anti- 
septic precautions are taken that annoying the patient by experi- 
mental dietetics is hardly justifiable, and I have found solid diet 
with reasonable restriction to be, on the whole, the most satisfac- 
tory. Patients who are fairly robust will naturally endure privation 
of food and drink better than the feeble and anaemic. 



476 DIET IN DISEASE 



Empyema 

The dietetic treatment of empyema is based upon the need for 
nutrition to supply the drain on the system of the constant excre- 
tion of pus, and fatty food, such as butter, cod-liver oil, and cream, 
should therefore fill a large portion of the dietary. The general 
supporting treatment prescribed for the early stages of pulmonary 
tuberculosis is recommended (p. 461). 



DIET IN DISEASES OF THE CIRCULATORY SYSTEM 

AND BLOOD 

Diseases of the Heart 

The proper dietetic treatment of advanced heart disease deserves 
careful consideration, for on it to a great extent depends the pa- 
tient's comfort, if not the prolongation of his life. It cannot be said 
that the several conditions of cardiac enlargement, valvular disease, 
fatty degeneration, etc., demand different forms of treatment per se, 
but there are certain general principles which should be observed 
in any case when particular symptoms arise. The dietetics of car- 
diac diseases may, accordingly, be conveniently reviewed together. 

Pathological Physiology. — The general conditions involved are 
largely physical, or rather mechanical — perhaps more so than in any- 
other form of disease. 

1. We have to deal with a pump whose action is impaired by 
more or less weakness of its walls, or leakage or obstruction of its 
valves, or which is overworked by the imposition of increased re- 
sistance. 

2. The balance of food pressure in the vessels is usually disturbed 
and the rate of blood flow is altered. 

3. As the disproportion increases between the driving force or 
the resistance of the vessels and the volume of the fluid to be pro- 
pelled, there is apt to be leakage of serum in various situations, 
producing dropsies or general anasarca. Or these conditions may 
result from a diminution in the vitality of the peripheral blood ves- 
sels or changes in the composition of the blood itself. 

4. The rate of absorption of the materia alimentaria by osmosis 
depends as much upon the activity of the circulation — i. e., upon the 
rapidity of renewal of the layer of blood in the capillaries of the 
absorbing surface — as upon the density and composition of the 
blood, the action of individual cells, or any other factor. A feebly 
beating heart or an obstructed vascular system promptly checks 
absorption. Moreover, the reabsorption of transuded serum will 
depend upon the reversal of the conditions which originally caused it. 

5. The elimination of waste and the various processes of secre- 



THE CIRCULATORY SYSTEM AND BLOOD 477 

tion depend upon almost identical conditions with absorption, and 
while not due merely to filtration, they are nevertheless controlled 
very promptly by alterations in blood pressure and in the velocity 
of the current. 

Bearing in mind these elementary principles, the first question 
which arises in the dietetic treatment of advanced cardiac disease 
must concern the administration of fluids. 

Fluids. — An additional pint of fluid beyond the needs of the 
system may be sufficient to overtax the heart, alter the balance 
of blood pressure, disturb a temporary compensation, and precipi- 
tate anasarca, renal congestion, pulmonary oedema, or other symp- 
toms. On the other hand, with too little fluid the blood pressure may 
fall to a dangerous degree or there may not be water enough in 
the vascular system to maintain the free diuretic action which is so 
desirable. It is a well-known physiological fact that the heart, like 
any other muscle, does better work if it has reasonable resistance 
to overcome. Such are the problems, briefly stated, which must 
be met by the comparison from day to day of the amount and qual- 
ity of the urine, the degree of arterial tension, the force of the heart 
beat, and the possible presence of oedema. 

Dietetic Treatment. — It is difficult to formulate any but the most 
general rules for the dietetic treatment of chronic valvular disease 
of the heart. These cases often extend through a period of many 
years, and the variety of secondary symptoms which may appear is 
very great. The forms of valvular disease which are most apt to 
result in disturbances of digestion are those in which obstructed 
venous circulation results in local engorgement of the abdominal 
viscera, producing nausea, vomiting, and great distaste for food. 
Constipation and more or less chronic gastric and intestinal catarrh 
may be among the symptoms. The hypostatic congestion of the 
liver retards the activity of that organ, and the ingredients of the 
food which are brought to it by the portal system are no longer 
properly elaborated, so that general nutrition and assimilation suffer 
in consequence. A depleting diet is, therefore, sometimes to be 
recommended, and concentrated food is required to prevent over- 
burdening the circulation. If gastric catarrh necessitates the use of 
fluid food, the quantity of beverages taken in addition should be 
considerably restricted. When acute attacks of indigestion super- 
vene in the course of chronic valvular disease, the bowels should 
be kept thoroughly open, and a diet of milk, beaten eggs, and 
broths, taken once in three hours, must be prescribed for a few 
days, after which boiled fish, broiled chicken, scraped beef, beef- 
steak, or rare roast beef may be added. Fats, farinaceous foods, 
and sugars should not be allowed, owing to their tendency to pro- 
duce flatulency and aggravate existing symptoms. The use of 
alcoholic stimulation may at times become necessary, and whisky 



478 DIET IN DISEASE 

diluted in some non-effervescing water is perhaps the best. Beer 
should be particularly avoided, and recommendation of the regular 
use of stimulants, in this as in other forms of chronic disease, should 
be made with great caution lest the alcoholic habit be acquired and 
become permanent. Patients with sudden cardiac dilatation, such 
as sometimes occurs during convalescence from typhoid fever, need 
to return to a milk diet. 

When acute symptoms of palpitation, dyspnoea, etc., develop, the 
patient should never eat very much food at one time. It is better 
to take four or five meals a day, if necessary, and eat only small 
quantities. A large meal always distends the stomach considerably 
for several hours, causing this organ to elevate the diaphragm and 
displace somewhat the heart, which lies upon it, and diminishing the 
vertical diameter of the chest. The heart may become irritated by 
the mechanical pressure to which it is subjected by a moderate 
degree of displacement, and it is indirectly affected by the greater 
difficulty of breathing, as well as by reflex irritation from the 
disordered stomach. All food which is liable to ferment in the 
stomach, such as sugar and indigestible starches and fats, must be 
particularly avoided. Gastric catarrh is readily excited and aggra- 
vated by coarse or fermenting food. On this account also the use 
of strong alcohol should be forbidden except in the case of aged 
and feeble persons, to whom light wine or diluted spirits may be 
given. The regular use of tobacco should be prohibited, and tea 
and coffee, if permissible, are to be taken only in very dilute form. 
The tendency to constipation can be overcome by attention to diet, 
and a moderate amount of fruit, such as baked or stewed apples, 
stewed prunes, and grape fruit, may be allowed between meals. 

CARDIAC VALVULAR DISEASE IN CHILDREN 

Children who have chronic valvular disease or enlargement of 
the heart, but who are not strictly confined to bed, should be closely 
supervised in regard to their habits of eating. They should eat 
slowly and moderately, and have their meals at regular intervals, 
taking the principal meal at noon, and a light supper two hours 
before bedtime. In general, animal food is better for them than 
vegetables, but they may eat the lighter fresh vegetables, such as 
spinach, tomatoes, or stewed celery in season, and sometimes a little 
roast or mashed potato. Rice and macaroni may be given. Bread 
should be only eaten dry or toasted. Sweets should not be allowed, 
except very rarely, when a taste of jam or preserves may be given. 
Such substances are apt to cause flatulency and palpitation, if not 
more serious disturbances, and everything depends upon saving the 
heart from excitation or strain. All food should be very simply 
cooked, and too great variety is harmful. 



THE CIRCULATORY SYSTEM AND BLOOD 479 

In acute endocarditis it is very important to avoid all food likely 
to cause dyspepsia. Raw eggs with brandy, broths, and chiefly milk 
must be prescribed, and if the stomach is weak and irritable, a part 
of the nutriment may be given per rectum (p. 408). 



DIETETIC TREATMENT OF THE SENILE HEART 

In persons past middle life the heart may become enfeebled from 
a variety of causes independent of inflammatory conditions or valv- 
ular lesions. Fatty degeneration is a very common cause of such 
weakness, and in other cases the heart muscle may gradually lose 
its normal strength and " tone " from strain, or a disturbance of 
balance between its' power and the peripheral resistance to be over- 
come. In the aged the arterial walls become less and less resilient, 
if not actually rigid, from fibrosis or calcareous deposit, and, more- 
over, the heart suffers no less than other organs from impaired nutri- 
tion. In such cases the prolongation of the patient's life as well as 
the maintenance of his comfort may be fostered by attention to 
dietetics. 

A weak heart implies impaired circulation in the gastric vessels, 
and hence the gastric juice becomes poor in quality and lessened in 
quantity. Digestion is consequently retarded, and absorption of 
food products is less active than it should be. The heart and the 
stomach being both supplied by branches of the vagus nerve, it is 
easy to understand how gastric irritation, caused by products of 
malfermentation, organic acids, accumulated undigested food, or 
gaseous distention, may affect the heart through reflex action. Me- 
chanically, too, a stomach distended by gas presses upon and irri- 
tates the heart. Balfour (The Senile Heart) says : " If the heart 
is weak the discomfort induced by such irregularities is after mid- 
dle life more apt to be felt in connection with that organ than 
in the stomach itself." The result is intermission in the pulse rate, 
unevenness in force and frequency of the heart beat, its " fluttering " 
action, and sensations of palpitation, precordial distress, fulness or 
constriction, and dyspnoea. In order to avoid these symptoms as 
far as possible, the patient must have his diet carefully supervised. 
A sufficient interval — fully five hours — must always elapse for the 
complete digestion of one meal before a second is taken, and be- 
cause the gastric juice is feeble it is best not to allow more than 
four or five ounces of fluid of any kind to be taken with the meals. 
While sufficient variety of food may be allowed to maintain a fair 
appetite, it should never be so great as to entice the patient to eat 
too freely. 

Balfour summarises excellent rules for dieting to be followed by 
patients whose cardiac action is enfeebled by any cause, but espe- 
cially for the condition described as " the senile heart." 



4^0 DIET IN DISEASE 



Balfour s Rules for dieting for Weak Hearts 

" I. There must never be less than five-hour intervals between 
meals. 

" 2. No solid food is ever to be taken between meals. 

" 3. All those with weak hearts should have their principal meal 
in the middle of the day. 

" 4. All those with weak hearts should have their food as dry as 
possible." 

A good typical menu is given by the writer above quoted : 

Balfour s Diet for the Senile Heart 

" Breakfast, 8.30 a. m. — Dry toast, one small piece — one or one 
and a half ounce — with butter ; one soft, boiled egg, a small piece 
of whitefish ; three to five ounces of tea or coffee with cream and 
sugar, or an infusion of cocoa nibs, or milk and hot water, or cream 
and Seltzer. Sometimes oatmeal porridge is permissible, but not 
over three or four ounces should be taken. 

" Principal Meal, 1.30 or 2 p. m. — Fish, such as haddock or sole, 
or meat and pudding. Two courses only are allowed. No soups, 
pickles, pastry, or cheese. Whitefish and short-fibred meat only 
are allowable. The fish may be boiled in milk. A little spinach or 
one potato may sometimes be eaten, or a half pound of fruit, such 
as pears, apples, or grapes. Four to five ounces of hot water may 
be drunk with each meal, but no more. 

" 5 to 6 p. m. — Three to four ounces of tea (one teacupful) infused 
for four minutes may be drunk, but absolutely no solid food is to be 
taken with it. If desirable, a teaspoonful of Liebig's extract of meat 
may be stirred in with the tea. 

" Supper, 7 p. m. — Whitefish and a potato or toast and pudding, 
or milk pudding, or bread and milk, or revalenta made with milk or 
Liebig's extract. 

" Bedtime. — Four to five ounces of very hot water, sipped, helps 
the patient to fall asleep." 

Upon this very limited regimen the patient, if heavy and water- 
logged, at first loses weight by absorption of " cedematous soakage," 
or if much wasted he may gain in weight. In this manner the natu- 
ral equilibrium of the body is re-established. 

In not too critical cases a little more latitude is permitted, and 
such vegetables may be occasionally eaten as asparagus, onions, 
leeks, tomatoes, lettuce, cress. The heavier, coarser vegetables (like 
cabbage, sprouts, turnips, parsnips, carrots, beets, legumes), pastry, 
nuts, dried fruits, and sweets of all kinds are forbidden. 

Equal care mut be given to the selection of proper beverages. 
If there is much palpitation, tea, coffee, and chocolate must be pro- 



THE CIRCULATORY SYSTEM AND BLOOD 48 1 

scribed. In many cases Balfour allows a little weak tea, made by 
infusing a teaspoonful (about one hundred grains) in four or five 
ounces of water for only three or four minutes. Alcathrepta may 
be drunk. The two latter beverages may be taken at 5 p. m. or 
on retiring, when the stomach is empty. They must not be made 
too sweet. 

No champagne or effervescing drinks are allowed, and all alco- 
holic beverages should be given only in moderation. If more than 
two ounces (a claret-glassful) of one of the stronger wines is taken, 
it excites acid dyspepsia, and claret, Burgundy, or hock should not 
be allowed in greater measure. A small glass of port or sherry may 
be drunk twice a day ; but, as Balfour observes, there is so much 
idiosyncrasy in the digestibility of wines that in general plain liquor 
is better for these cases and in the small quantity recommended in 
the menu given above. Alcohol is by no means a necessity, and 
many patients are better without any. He has great faith in the 
stimulating properties of hot water, slowly sipped, and says : " This 
will be found to have quite as good an immediate effect upon the 
heart as alcohol. " 

It has been elsewhere shown that the frequent acts of degluti- 
tion performed in sipping any fluid tend to increase the pulse rate 
slightly through reflex stimulation of the vagus branches which 
are concerned in the act. 

As the heart becomes more and more feeble, the inactive circu- 
lation, perhaps aided by alteration in the composition of the blood 
or by albuminuria, results in the production of localised cedema or 
general anasarca. 

In referring to the use of dry diet for these conditions as occur- 
ring in connection with the senile heart, Balfour says : " When there 
is anasarca, or any evidence of soakage in any dependent part of 
the body, it is of the greatest importance to place the patient, for 
a time at least, on the driest possible diet, and not too much of 
it. ... I have seen a considerable amount of cedema of the lower 
limbs disappear within twenty-four hours before there had been 
time for any change in the heart, which was feeble and dilated." 
His dry diet is as follows : 

Breakfast. — A single slice of dry toast, without butter. A cup of 
tea (infused only four minutes). 

Dinner. — Two lean chops, or their equivalent in chicken or fish. 
No vegetables. Dry toast ad libitum. Half an ounce of brandy, 
whisky, or Hollands in three ounces of water. 

Supper. — As much dry toast as desired. Half an ounce of 
liquor, as at dinner. 

Nothing else is allowed ; but if the patient is thirsty, very hot 
water may be sipped between meals. This, Balfour maintains, is an 
excellent cardiac tonic. 



482 DIET IN DISEASE 



ANGINA PECTORIS 

The only indication to be met in the dietetic treatment of angina 
pectoris is to reduce the arterial tension. A vegetable diet with re- 
stricted fluids, and no alcohol, is to be recommended. These pa- 
tients often are subjects of the gouty diathesis, and the directions 
for diet in that condition are to be observed. (See Gout.) 

CARDIAC PALPITATION 

The dietetic treatment of cardiac palpitation is sufficiently indi- 
cated under the heading of Flatulent Dyspepsia. Overeating should 
be avoided, as well as all stimulating foods and beverages. Tea, 
coffee, and tobacco should be forbidden — at least temporarily. Ef- 
fervescing drinks of all kinds, from their tendency to produce flat- 
ulency, should also be proscribed, as well as all sweets and much 
starchy food. Laxative foods, especially fruits, will be found useful. 

ARTERIO-SCLEROSIS 

In those cases in which renal inadequacy is a pronounced feature 
it will be well to put the patient upon a milk diet for several weeks. 
In general a non-stimulating diet is requisite, with a minimum of 
butcher's meat, and no strong condiments, richly cooked dishes, or 
alcohol should be allowed. 

ANEURISM 

In aneurism of the larger arteries the vessel wall is dilated and 
thinned, and rupture is liable to occur at any time from increase 
of the blood pressure or obstruction to the circulation produced by 
sudden movement, or otherwise. The most favourable result of 
treatment which can be anticipated is thickening of the diseased 
vessel by the deposit of coagulated fibrin from the blood. The co- 
agulability of the blood varies with its composition, and is favoured 
by increased density of the blood and by structural changes in its 
albuminous ingredients. To a limited extent this process can be 
aided by diet. The object to be attained in the dietetic treatment 
of aneurism is to reduce the volume, and consequently increase the 
density of the blood. The latter does not necessarily increase its 
coagulability, however. This method of treatment was originally 
formulated by Bellingham and Joliffe Tufnell, of Dublin, and it is 
now described by the latter's name. It is only less rigid than the 
very old method of Valsalva, who gave half a pound of pudding 
morning and evening, and nothing else — practical starvation ! In 
conjunction with the dietetic treatment absolute rest of the patient 
is enjoined ; he should lie horizontally in his bed, and not be per- 



THE CIRCULATORY SYSTEM AND BLOOD 483 

mitted to make exertion of any kind, and mental strain and emotion 
should be carefully guarded against. He should be fed by a nurse, 
and not allowed to sit up at any time. By rest alone the rate of the 
heart beat is materially slowed, and this is favoured also by the re- 
duced diet. The artery, in consequence, is distended less and less 
often and is submitted to less pressure. The exact treatment recom- 
mended by Tufnell is as follows : 

TufnelVs Diet 

Breakfast. — Two ounces of bread with a little butter and two 
ounces of milk. 

Dinner. — From two to three ounces of meat without salt and 
four ounces of milk ; for a portion of the milk an ounce or two of 
claret may be substituted. 

Supper. — The same as the breakfast. 

This extremely rigid diet is apt to be rebelled against by most 
patients, but it serves as a basis for the commencement of other 
treatment, and if it be found impracticable to adhere to it, the quan- 
tity of food will have to be slightly increased. It may be necessary 
to double the quantity of milk and increase the amount of bread 
or vary it with crackers or some light form of starchy diet. The 
fluid, however, is in all cases to be restricted as much as possible. 
Patients usually complain bitterly of thirst, and while it is more 
desirable to restrict the fluids than the solids in the dietary, the 
thirst may be alleviated somewhat by the use of acidulated drinks, 
such as sour lemonade, dilute phosphoric acid in cinnamon water, 
etc. The danger which menaces the patient and the object of his 
treatment should be clearly explained to him and his co-operation 
secured in the effort for his relief. It is customary to employ iodide 
of potassium and morphine in moderation for their sedative action 
upon the circulation and the system generally. Many cases are of 
syphilitic origin, and they are particularly benefited by the potas- 
sium iodide. Upon this reduced diet improvement in physical signs 
of the aneurism — such as diminished pulsation and intensity of bruit 
and lessened pain — is occasionally quite decided. In favourable 
cases improvement may be looked for at the end of a week, and if 
the dietetic treatment is persisted in for six weeks, the benefit may 
be considerable. Tufnell himself reports several cases in which the 
aneurismal sac became lined with a thick coating of fibrin. 

There are many cases of aneurism outside the province of surgi- 
cal treatment which are incapable of relief from any diet, but the 
method above described is decidedly worth a trial in an otherwise 
hopeless condition. I have several times known it to produce con- 
siderable lessening of pain, dyspnoea, and other symptoms, but it 
requires firmness and perseverance to carry it out successfully. The 



484 DIET IN DISEASE 

curative results have, unfortunately, not verified Tufnell's original 
claims, and as pointed out by Loomis, if the method is too rigidly 
and too long enforced — for six or eight weeks — an extreme degree 
of anaemia may develop and leave the patient worse off than before. 
If the Tufnell diet is not prescribed, non-stimulating food only 
should be allowed, consisting chiefly of simply cooked fresh vege- 
tables and fruits, with but little meat. Anything likely to produce 
flatulency or gastric dyspepsia should be carefully avoided, and 
strong alcohol must be forbidden. 

Anaemia — Chlorosis 

Pathological Physiology. — The proper nutrition of all the tissues 
of the body is directly dependent upon the quality of the blood 
plasma and of the amount of oxygen conveyed by the corpuscles. 
A very slight departure from the average composition of these ele- 
ments will sooner or later result in diminishing the nutrition and 
functional activity of all the organs in the body, notably those of 
the digestive system. 

Anaemia, whether acute and due to haemorrhage or disease, or 
chronic from any cause, by depleting the cellular elements of the 
blood, interferes with the proper oxidation of food after absorp- 
tion. On the other hand, a diet which is insufficient in amount 
or inappropriate in quality, if long continued, is certain to pro- 
duce an impoverished condition of the blood with a diminution in 
the number of corpuscles ; hence there is a double relation exist- 
ing between the power of the blood to insure complete absorption 
and metabolism, and of the food itself to maintain the normal bal- 
ance of the ingredients of the blood. Anaemia, therefore, demands 
special feeding, the basis of which should be an effort to restore as 
soon as possible the proper number of red corpuscles and the nor- 
mal quantity of other ingredients of the blood by a diet which is 
nutritious and abundantly rich in nitrogenous food given in some 
easily assimilable form. When proteid food is excluded from the 
diet for some weeks the haemoglobin of the red blood corpuscles 
is considerably reduced in amount and hydraemia ensues, but the 
pigment is always increased by an excess of nitrogenous food. 

Anaemia and chlorosis are most common at the age of puberty, 
and immediately thereafter, among young girls who are growing 
or who are overworked at school or in factories while beginning 
menstruation, and who are improperly fed. The diversion of consid- 
erable nervous energy for other functions than those of the circula- 
tion at this time may interfere somewhat with the nervous mechan- 
ism of digestion and absorption. In other cases there is a con- 
stitutional or hereditary weakness of the digestive system, which 
is aggravated by an exceptional strain or overwork of the nervous 



THE CIRCULATORY SYSTEM AND BLOOD 485 

system. The phenomena of growth and development of the differ- 
ent organs necessitates the consumption of a relatively larger quan- 
tity of good food than is needed later in life for merely maintaining 
the equilibrium of the tissues and restoring the balance of material 
used in the production of energy. Growth implies the building up 
of new material and a renewal of the old as well. At the period of 
growth, therefore, there are always unusual demands upon the 
nervous system, and overstrain at this time is to be especially 
guarded against. 

Symptoms. — Among the many symptoms referable to the nerv- 
ous system which occur in the course of protracted anaemia are 
languor, vertigo, various forms of neuralgia and megrim, with in- 
definite muscular pains, which to some extent are produced by en- 
feebled circulation, which allows waste material produced by mus- 
cular action to accumulate in the tissues. Depression of spirits and 
drowsiness are also observed, and palpitation is easily excited. The 
poor circulation may result in the production of fainting, or of 
oedema in the lower extremities. In advanced anaemia it is found 
that not only is the normal rate of tissue metabolism impaired, but 
there may be modifications in the relative consumption of certain 
foods by the tissues. A large excess of urea is commonly observed, 
which indicates an active combustion of nitrogenous substances. 
The view is widely held that owing to the small number of the red 
disks, or oxygen carriers, the final oxidation of fatty matter is re- 
tarded, and it is for this reason that anaemic subjects very often 
appear plump or even corpulent from the deposition of a large 
amount of fat derived from incomplete combustion of fats and 
starches, whereas their muscles, from the increased nitrogenous 
waste, are reduced in size and are weak. Van Noorden, Kraus, 
Bohland, and others dissent from this argument and believe that 
chlorotic patients feel tired, sleep long, and are disinclined to ex- 
pend energy in muscular exertion, and less energy than usual goes 
into heat production, and as they sometimes eat abundantly of 
sugars and starches, they necessarily store up fat. 

Rest, Exercise, and Air. — In many cases of extreme anaemia, 
found especially among young chlorotic girls, the dietetic treatment 
must be accompanied by careful regulation of all hygienic condi- 
tions. Sufficient rest for the tissues, and especially for the digestive 
organs, must be secured. These patients, who appear so well 
nourished, may in reality be quite feeble, and it is a great mistake 
to compel them to rise early and perform tasks and indulge in 
exercises of the same character and degree with those of healthy 
children. For many patients it is well to insist on prolonged and 
continuous rest in bed. For others it will suffice to restrict the ac- 
tivities of the day by permitting the patient to rise shortly before 
noon, and to insist upon rest being taken on a lounge both before 



486 DIET IN DISEASE 

and after meals in order to secure more perfect digestion. These 
patients must be cautioned against allowing themselves to become 
unduly fatigued. They are often able, under the influence of stim- 
ulants and excitement of various sorts, to perform feats of exercise 
or endurance which are equal to those of healthy persons, but a 
strong reaction is certain to follow, and a steady but slow progress 
will often be checked for several weeks by infringement of neces- 
sary regulations. In such cases, however, as soon as decided im- 
provement is evident, and in all the milder cases, it is desirable to 
enforce rules for gentle exercise in the open air, and the patient 
should be outdoors nearly all the time whenever the weather per- 
mits. The exercise should be supervised and slowly increased in 
stout subjects, so that they gradually consume their superfluous fat. 
If the climate is unfavourable the cure will be much more rapid 
if the patient can be moved to a more salubrious locality. Fresh air 
is more important than exercise, for an abundant oxygen supply 
increases the appetite and distinctly favours the assimilation of the 
food. 

Dietetic Treatment. — The dietetic treatment of anaemia requires, 
in the first place, that the most nutritious food should be supplied ; 
secondly, care must be taken to insure its complete digestion and 
absorption. In all cases of anaemia the impoverished and watery 
condition of the blood reacts unfavourably upon the character of 
the digestive secretions and diminishes their organic elements. The 
secretions are therefore unable to digest the food with the necessary 
vigour, and it is often desirable to re-enforce them by the use of 
artificially prepared ferments or to give predigested food, making 
use of pancreatin, in the preparation of animal food, and diastase 
or malt extracts for the predigestion of amylaceous food (see pp. 

353, 354)- 

At the commencement of treatment rest and a small amount of 
food may be required, but with improvement of the digestive organs 
the quantity of food must be rapidly increased, and four or five 
meals a day may be given. At first, if milk is well borne by the 
enfeebled digestive system, and if it is not distasteful to the patient, 
it should be the principal food. It may be drunk between meals, 
and especially at night on going to bed. Some of these patients 
who cannot digest milk with facility are able to take a mixture of 
equal parts of cream and hot water with ten grains of bicarbonate of 
soda and a teaspoonful of brandy to the tumbler (Yeo). Eggs in 
all forms which are of fairly easy digestion are an excellent food 
for anaemic subjects, and rare meat should be given in consider- 
able quantities two or three times a day. Sandwiches made with 
pounded meat or beefsteak almost raw, which is placed between 
thin slices of bread and butter, may be taken with meals, or as a 
light lunch in the middle of the morning and afternoon. Inserting 



THE CIRCULATORY SYSTEM AND BLOOD 487 

a crisp lettuce leaf in each sandwich makes it still more palatable 
and wholesome. Patients of this class often object very strongly 
to eating meat, and prefer pastry and sweets, but with tact and per- 
suasion they can usually be induced to take it in some form. Meat 
broths and consommes may be thickened with scraped meat, or raw 
scraped beef may be added to chocolate or Burgundy, or may be 
eaten in any manner agreeable to the patient. In this way large 
quantities of meat in an easily digestible form may be taken with- 
out tiring of it, as fat anaemic women are very apt to do. Young 
chlorotic girls should receive at least five or six ounces of albumin 
per diem. See gives as much as fourteen ounces of raw meat daily 
in some cases of chlorosis, and finds it especially serviceable for those 
patients whose weak stomachs rebel against the use of the different 
preparations of iron. 

Anaemic patients often feel worse during the first half of the day. 
They then complain most of headache, languor, and anorexia, but 
they should be encouraged to begin the day early with nourish- 
ing albuminous food to counteract this condition. Van Noorden's 
system at the Berlin Charite is excellent, and he describes it as 
follows : 

" I recommend chlorotic girls to drink slowly half a litre of milk 
of the best quality while they are yet in bed in the morning. They 
must take time, and occupy at least a quarter of an hour in con- 
suming this quantity. They ought to rise half an hour later, and 
they should be rubbed briefly with a dry rough woollen towel. This 
is to be followed by the breakfast, consisting of a small cup of tea, 
one or two slices of buttered toast, and plenty of meat. I con- 
sider it extremely desirable — the physiological reasons for this are 
easy to defend — that these patients should take in at breakfast, 
before the daily work commences, as much albumin as possible. 
Two and a half hours later some bread and butter and two eggs 
are to be eaten, followed immediately afterwards by drinking a 
quarter of a litre of milk. If considered advisable for special 
reasons, a small glass of sherry is now permissible." 

If the large quantities of meat recommended are not perfectly 
digested and absorbed, it is well to prescribe some preparation of 
pepsin with dilute hydrochloric acid. A concentrated meat diet al- 
most always produces constipation if this condition does not al- 
ready exist as a result of the anaemic and atonic condition of the 
intestinal wall, or the giving of iron. It is well to counteract this 
tendency by the use of draughts of hot water and of purees of fresh 
vegetables, whole-meal bread, oatmeal, and such fruits as stewed 
prunes, apples, and the juice of oranges and grape fruit. (See Con- 
stipation.) 

The various Italian pastes, such as macaroni, vermicelli, and 
polenta, with meat gravies, are suggested by Yeo. But with those 

33 



488 DIET IN DISEASE 

patients in whom there is a tendency to overproduction of fat, 
withholding of hydrocarbons from the diet is highly desirable. 

For others who, besides being anaemic, are thin and poorly 
nourished, it is well to add some simple forms of starchy food and a 
good deal of fat with the meals. Van Noorden says : 

" For a well-nourished, moderately fat, chlorotic girl, weighing 
sixty kilos, I would consider the following diet as eminently suitable : 

" 120 grammes albumin = 492 calories. 

60 " fat = 558 

270 " carbohydrates = 1,110 " 

Total 2,160 

(i. e., 36 calories per kilo of body weight.)" 

The eating of fats is to be encouraged to the limit of toleration. 
Cream and large quantities of butter are recommended when easily 
digested, and they can be made to replace cod-liver oil when the 
patient is unable to take this form of fat. Many patients can digest 
broiled fat bacon with ease. Two or three eggs beaten with boiling 
water or milk, with the addition of sugar and spices and a table- 
spoonful of brandy or sherry, make a useful form of eggnog, which 
can be given two or three times during the day between meals. 

The use of glycerin extracts and of emulsions of bone marrow 
has been advocated for anaemia, but the results have not been mark- 
edly satisfactory. The method of preparation of the marrow is 
described on p. 196. 

The condition most improved is chlorosis, but it is claimed 
that some cases of pernicious anaemia have been helped. 

Most anaemic patients have no appetite, or lose it, during the 
early part of the day, and careful attention should therefore be 
given to making all their food as agreeable to them as possible in 
taste and manner of serving. Meat should be prepared so as to 
require the least possible effort in mastication, and much more food 
can be consumed in a fluid and semisolid form. 

Condiments are serviceable, for they render simple food more 
agreeable and stimulate the enfeebled gastric secretion. Moleschott 
insists on the free use of salt by chlorotic patients on account of its 
supposed favourable action in restoring the blood corpuscles and 
plasma. Vinegar, pickles, gravies, and sauces should be avoided. 

Alcohol is not indicated for all, but there are some patients who 
are benefited by its use, and the best form of alcoholic tonic for an 
anaemic patient is a good rich claret, Burgundy, or Madeira. Some of 
the milder cases, especially in women in whom the digestive organs 
are not particularly disturbed, do very well on porter or stout, or 
one of the various malt preparations, which may be taken with the 
noondav meal or at bedtime with a few crackers or a raw-beef sand- 
wich. The latter is a prescription very serviceable in those cases in 



THE URINARY SYSTEM 489 

which insomnia is a harassing symptom. There is no apparent con- 
nection whatever between the absorption of alcohol and the forma- 
tion of new blood cells, although there is a popular idea to the effect 
that red wine produces red blood. Alcohol, however, often does 
promote the accumulation of fat, and this is most undesirable in 
anaemic subjects who already possess that tendency. 

PERNICIOUS ANAEMIA 

Hunter argues for the use of an exclusively farinaceous diet for 
pernicious anaemia, on the ground that in health a proteid diet 
causes more extensive destruction of the corpuscular elements of 
the blood than a farinaceous one, and in this disease, on account 
of putrefaction in the intestine, the blood destruction is increased 
by nitrogenous diet. This theory is in opposition to all others, and 
the most satisfactory and rational treatment consists in giving pre- 
digested milk, eggs, beef broth and juice, etc., in as large quan- 
tities as both stomach and rectum will absorb. 

There is defective assimilation of proteid foods, and hence they 
should be thoroughly predigested (see p. in). 



DIET IN DISEASES OF THE URINARY SYSTEM 

Modifications in the Urine caused by Food 

The quantity as well as the composition of the food eaten exer- 
cises an important influence over the composition of the urine. 
Animal food increases the acidity of the urine and naturally also 
its nitrogenous elements, urea, uric acid, and urates, and vegetable 
food increases the carbonates and earthy salts. A concentrated 
diet restricted in fluids as well as solids reduces the water of the 
urine, and makes it relatively more acid, although the absolute 
quantity of acid may not be increased. Conversely, watery foods, 
milk, succulent fruits and vegetables, and all beverages increase 
the quantity of urinary fluid and tend thereby to lessen its acidity 
and density. Cantani dissents from the common view that the or- 
ganic acids, such as fruit acids, form carbonates which promote 
alkalinity of the urine, and says that this is true of small quantities, 
but that larger amounts or the continued administration of these 
acids makes the urine strongly acid. Phosphatnria or the excessive 
deposit of phosphates in the urine is best treated dietetically by the 
use of meats, eggs, cheese, cereals, and legumes. Potatoes, fresh 
green vegetables, and fruits should be avoided. 

A diet rich in fatty food, or an excess of cod-liver oil, may some- 
times give rise to fat in the urine, or lipuria. The volatile fatty acids 
may similarly be present. The presence of the fat makes the urine 



490 DIET IN DISEASE 

somewhat turbid, and oil globules and fat crystals may sometimes 
be seen under the microscope. 

A milk diet makes the urine alkaline, and increases the indican. 

Foods producing oxaluria are described under Oxaluria. 

The odour of asparagus in the urine is explained on p. 172. 

Acute Nephritis 

Symptoms. — Acute nephritis is an inflammation of the kidneys, 
which is principally caused by exposure to cold and wet, by certain 
medicinal poisons, or by the toxins developed in the course of acute 
infectious fevers, especially the exanthemata and diphtheria. It is 
unnecessary to discuss its varieties here, as the dietetic treatment is 
the same for all. 

Among the important symptoms are anaemia and a scanty secre- 
tion of urine containing abundant albumin with casts and blood. 
Anasarca and effusion into various serous cavities, such as those of 
the pleura and peritonaeum, may occur. The arterial tension is 
increased. The patient must be kept in bed to insure a uniform 
temperature of the body, and facilitate the use of measures to pro- 
mote perspiration. 

Dietetic Treatment. — The dietetic treatment must be adapted 
to prevent overloading the digestive organs, which are easily de- 
ranged, and to prevent overworking the kidneys. A light diet is 
therefore necessary. The patient will do best to live exclusively 
upon milk for some days, until the functional activity of the kid- 
neys is restored. The importance of this should be explained to 
him and insisted upon. Between four and seven pints are to be 
taken daily, diluted with Vichy or carbonic-acid water. If the 
bowels are loose, lime water may be added instead ; or if con- 
stipated, magnesia solution. If the liver seems inactive, skimmed 
milk or buttermilk may agree better. Milk sometimes causes gas- 
tric oppression. If sipped slowly, or taken with a teaspoon, this 
may be overcome, for it is then diluted with the saliva. 

If milk is strenuously objected to or actually disagrees with the 
patient, other simple foods may be allowed, such as koumiss, but- 
termilk, and gruels of oatmeal, groats, rice, barley flour, or arrow- 
root. These forms of starchy food should be prepared without 
much sugar, but a little cream may be added or, if preferred, the 
juice of a lemon, but no vegetables are permitted. If the patient is 
feeble, strong beef tea or beef or chicken broth are sometimes to be 
recommended, but, in general, so long as the symptoms are at all 
acute it is necessary to withhold all meat preparations from the 
diet. This is especially true in the case of young children. Animal 
broths dissolve substances from meat which may develop into toxins 
and irritate the kidnevs. 



THE URINARY SYSTEM 491 

When the kidneys become more active and the character of the 
urine improves, the diet may be increased by such articles as bread 
and butter, plain puddings, lettuce, or water cress with plain French 
dressing, stewed apples, grapes, oranges, etc., but whenever pos- 
sible the food should consist largely of milk for a long period. 
Later, eggs and even meat broths may be allowed, and finally a 
little white meat of poultry. 

Any return of the albuminuria should be immediately met by a 
reduction in the diet to its original simplicity — chiefly milk. 

A patient may lose thirty or forty grains of albumin in twenty- 
four hours without serious harm, but if three hundred to four hun- 
dred grains are lost the condition is in itself alarming, for he is 
losing from one fifth to one fourth of his total albuminous food 
through leakage of the kidneys — i. e., he is passing daily in the 
urine one twelfth of the nutrient matter of his blood (Granger 
Stewart). A pint of milk supplies about an ounce of albumin and 
casein, thus replenishing the waste. 

The lactose of milk is sometimes given separately for its diuretic 
action. See gives it up to three ounces in twenty-four hours, to be 
drunk in two quarts of water, and he believes it acts best when car- 
diac dropsy is also present and the quantity of albumin is not large. 
I have found it difficult to push its use to such a degree without 
causing dyspepsia and a decided dislike for it. Milk is undoubt- 
edly a good mild excitant of renal activity, but this is due to its 
water as much as to any other ingredient, and the diuretic effect of 
lactose is much overrated. 

Should vomiting occur at any time, the diet must be again re- 
duced, or it may be advisable to give the stomach complete rest for 
ten or twelve hours. To increase the activity of the skin and wash 
the casts and debris of granular matter and blood corpuscles from 
the renal tubules, the blood volume must be raised by the ingestion 
of abundant fluid, provided the tendency to dropsical effusions is 
not great. Water, alkaline, mineral, or effervescing waters, soda 
lemonade, or cream-of-tartar lemonade should be drunk freely, the 
latter especially if there is constipation (Dickinson). Osier rec- 
ommends the following: A drachm of cream of tartar in a pint of 
boiling water with the addition of the juice of half a lemon and a 
little sugar. To be drunk cold. 

It is a general rule to exclude all foods and drinks which may 
in any way irritate the kidneys, and the following are especially 
forbidden : Grills, roasts, sauces, pastry, spices, very acid foods, 
strong alcoholic drinks, tea and coffee. Strong wines, sweet wines, 
and all sorts of liquors are absolutely prohibited. If alcohol 
seems necessary for the stimulation of the heart, a little weak claret, 
white wine, or diluted whisky and some effervescing water may 
be given. 



492 DIET IN DISEASE 



ACUTE NEPHRITIS IN CHILDREN 

When the disease occurs in children, as often happens during or 
after acute infectious diseases, such as scarlatina and diphtheria, the 
diet must consist wholly of milk. During the most acute stage of 
nephritis the milk may be diluted one half with Vichy or water for 
its diuretic influence. It should be given in moderation, but often 
— say at least once in two hours. As the acute symptoms subside 
milk is to be ordered in full strength. 

Gradually other articles may be added, such as crackers, toast, 
porridge, rice pudding, cornstarch, junket, and blancmange. Orange 
juice may be taken freely, and an occasional baked apple with cream 
or a few stewed prunes will act favourably upon the bowels. 

It is best, as in the case of adults, to forbid meat broths, and 
eggs and meat in any form must be withheld for three or four weeks 
after the urine has regained its normal composition. Subsequently 
a menu may be composed from such articles as a chop, the breast 
of a chicken or partridge, a little broiled whitefish, a poached egg, 
oysters, custard, a baked mealy potato with fresh butter, stale bread, 
wine jelly, and fresh ripe fruits. 

Albuminuria — Functional Albuminuria 

Pathological Physiology. — Albuminuria may be produced by al- 
terations in the composition of the blood and by structural or 
functional changes in the kidney itself, or by both. The albumin 
is derived from the blood serum, which in turn comes from the 
protein of the food. Under ordinary circumstances proteid matter 
in passing through the body undergoes several transformations 
which affect its degree of solubility and its ability to osmose or go 
through animal membranes such as line the alimentary canal, the 
blood vessels, and the tubules of the kidney. Most protein taken 
into the body as food is not readily absorbed until converted into 
some form of peptone or albumose. These substances diffuse 
very easily, and their presence in the blood would render them 
liable to constant osmosis from the vessels into the lymph spaces 
or tissues almost immediately after absorption, but in their transit 
through the intestinal villi they are reconverted into serum albu- 
min, which does not osmose easily, and which therefore remains 
in the vascular system. A certain amount of albuminous mate- 
rial, however, must pass by osmosis from the blood vessels into 
the lymphatic channels, and thence into the tissues which surround 
them or which they penetrate. For serum albumin to pass into 
the urine it must osmose through two layers of cells — namely, the 
capillary wall of the blood vessel and the epithelial lining of the 
tubules of the kidney. Variations in the density of these, walls, and 



THE URINARY SYSTEM 493 

probably also alterations in the functional activity of the epithelial 
cells which compose them, will modify the rate of osmosis so that 
it may be completely checked, or it may be allowed to take place 
unhindered. The conditions of osmosis also depend upon the rela- 
tive density of the fluids on either side of the membrane, hence al- 
terations in the composition of the blood plasma may allow of the 
osmosis of serum albumin into the tubules of the kidney. It is im- 
portant to observe that the presence of serum albumin in the urine 
in excess not only indicates a functional or structural weakness in 
the kidneys themselves, or in the composition of the blood, but it 
represents actual loss of substance from the body — i. e., of material 
which is not yet converted into waste matter, but which is capable 
of furnishing nutrition to the tissues — in other words, there is a leak 
of nutrient matter from the kidneys. 

From the foregoing statements it might seem feasible to disre- 
gard the leakage and increase the amount of nitrogenous food suf- 
ficiently to counterbalance the loss sustained. The same plan might 
theoretically be thought to be of benefit in cases of diabetes, where 
it would seem quite possible to counterbalance the loss of saccha- 
rine material from the kidneys by ingestion of much larger quantities 
of starches and sugars ; but this is a fallacious comparison, for ex- 
cess of sugar is really a foreign body in the blood, while albumin 
is not (Granger Stewart). Clinically, however, it has been found 
that when either of these conditions of loss of substance from the 
blood exists in the kidneys it is better to withhold as much as possi- 
ble the particular variety of food which is leaking through them 
and reduce the work of these organs, hoping by rest, combined 
with other appropriate means of relief, to cure the faulty condition. 

Functional Albuminuria. — Temporary functional albuminuria is 
now recognised as occurring in many individuals without the signifi- 
cance of any structural or organic lesion of the kidney. This sub- 
ject has been exhaustively investigated by the medical examiners 
of life-insurance companies, for it is of great importance not only 
to discover the presence of albuminuria early, but to assign the 
proper significance to its presence. It is not many years since the 
detection of albumin in the urine was regarded as an infallible indi- 
cation of some form of renal disease, but the fact is now established 
that errors in diet and faulty assimilation produced by mental and 
nervous strain, overwork, and worry, and more particularly by the 
exhaustion of very rapid growth of the body in the later years of 
childhood and early youth, may occasion albuminuria. 

A solution of meat albumin experimentally transfused into the 
venous circulation of a dog, injected either subcutaneously or into 
the rectum, reappears unaltered in the urine, but serum albumin 
similarly injected is retained by the blood and does not cause albu- 
minuria, although the percentage of albumin in the blood plasma 



494 DIET IN DISEASE 

has been considerably raised above the normal. Moreover, if a 
man in health eats eight or ten raw eggs in the course of five or 
six hours, traces of serum (not egg) albumin may appear in the 
urine. The matter is of interest in connection with the diet for 
chronic Bright's disease (p. 497). Albuminuria thus produced is 
purely temporary, and is directly dependent on the nature of the 
food. So much of this proteid has been eaten that a portion of it 
is absorbed directly into the blood without the formation of inter- 
mediate products of digestion. Similarly this albumin will os- 
mose through the kidney. But if the digestive activity in the stom- 
ach is very great, a large number of raw eggs may be eaten, and 
as many as nineteen have been taken in thirty-six hours (Dolradin) 
without the appearance of albuminuria. It is no doubt true in such 
an instance, as suggested by Yeo, that the vigour of the digestion 
converts egg albumin into peptones, which finally form serum albu- 
min, whereas with a slower digestion more of the egg albumin is 
absorbed unaltered. 

According to the experiments of Stokvis, coagulated egg albu- 
min cannot be made to reappear in the urine of healthy animals, 
but raw egg albumin can. 

Oertel (Therapeutics of Circulatory Derangements, in von Ziems- 
sen's Handbook of General Therapeutics), as a result of numerous 
experiments upon man and animals in opposition to the above view, 
declares that " egg albumin, given in whatever quantity, is not nor- 
mally excreted as such by the kidneys, and does not cause albumi- 
nuria." The albumin absorbed is all destroyed in the blood or tissues 
and excreted as urea from the kidneys. He further says that " a 
great increase of albumin supplied to the blood causes no increased 
excretion of albumin by the kidneys, and, in particular, that egg 
albumin gives rise to no irritation of the renal vessels and no albu- 
minuria (nor does it increase an existing albuminuria)." 

This statement, if corroborated by further observation, would 
considerably alter the prevailing notions in regard to the advisa- 
bility of giving eggs to patients with chronic Bright's disease. 

Of all the varieties of albuminuria, those which are most amen- 
able to dietetic treatment are the functional form and that which 
accompanies chronic Bright's disease. The functional albuminuria 
which is produced by eating an excess of protein or by muscular 
fatigue, which results in the accumulation of large quantities of 
nitrogenous waste matter and interference with normal oxidation 
processes, is usually curable by ascertaining and removing the cause. 

It seems to be almost impossible to produce functional albumi- 
nuria in the lower animals, such as dogs, by overfeeding them with 
a very large excess of albuminous food. Voit caused a dog to absorb 
within twenty-four hours six times the amount of albumin contained 
in the blood plasma without exciting albuminuria. 



THE URINARY SYSTEM 495 

In the instance given above of albuminuria caused by eating 
large numbers of eggs, it was emphasised that the proteid in the 
urine is egg albumin and not serum albumin. It is stated, however, 
that occasionally serum albuminuria may be produced in man by 
eating large quantities of meat. If true, this is certainly very un- 
usual, and this form of albuminuria is by no means as readily induced 
as the glycosuria caused by an excess of starches in the food. But 
if albuminuria already exists, certain forms of nitrogenous food will 
greatly increase the amount eliminated by the kidneys. 

It is probable that some persons inherit a special weakness of the 
kidney structure or an abnormal irritability of the renal cells which 
favours the occurrence of albuminuria from slight provocation. 
Granger Stewart (Lectures on Important Symptoms of Albumi- 
nuria) states that he has observed in certain persons that cheese, 
pastry, and eggs are substances capable of producing temporary 
albuminuria. In one case this symptom was accompanied by oedema 
of the eyelids. 

In regard to the production of functional albuminuria from die- 
tetic errors Yeo argues, and I think correctly, as follows : " May not 
the true explanation be that the ingestion of so large an excess of 
albuminous material may throw upon the kidneys such an excess 
of nitrogenous waste (to be secreted) that a temporary functional 
hyperemia of the kidneys is excited, and that this leads to a slight 
escape of albumin from the blood? It appears to us that this is a 
sound physiological explanation of what is observed to occur, and 
accounts for its occurrence in fever or disordered constitution, and 
not in the perfectly sound and vigorous." 

Albuminuria also results from passive hyperemia of the ves- 
sels of the kidney, as well as from active congestion and inflam- 
mation. 

In functional albuminuria, when traces of serum albumin appear 
from time to time in the urine, it is found that the amount is pro- 
portionately increased by any special fatigue or exhaustion. It is 
possible, although it is by no means proved, that nerve currents 
supplying the epithelial cells of the renal tubules or the walls of the 
renal capillaries may cause a functional alteration in the activity of 
these cells, which compels them to exercise a selective action upon 
the albumin of the blood serum, and favours its osmosis. The theory 
is advanced by Mills, of Montreal, that the epithelium of the capil- 
laries possesses some at least of the functions of glandular epithelium, 
and that it is capable of controlling and varying the quality as well 
as the quantity of such substances as may pass through the minute 
capillary walls. 

Albuminuria is very common as a result of elimination of irritant 
poisons from the kidneys, and it is believed that the albuminuria 
usually present in diphtheria and the exanthemata is produced by 



496 DIET IN DISEASE 

the irritant effect upon the kidneys of toxins developed in these 
diseases which are being eliminated in the urine. 

Dietetic Treatment. — The frequent return of functional albumi- 
nuria should be regarded as an indication of special weakness of 
the kidneys in the same way that frequent glycosuria invites sus- 
picion of the strength of the digestive power of the liver, and it 
demands a careful regulation of the diet. Meat should be reduced 
in quantity, or temporarily forbidden, as well as all forms of alcoholic 
drinks or other substances liable to produce renal irritation, and 
the diet should consist chiefly of fruits, vegetables, and milk. Care- 
ful attention must be paid to increasing the activity of the bowels. 
When functional albuminuria is observed in children and adoles- 
cents, it is not necessary, nor is it advisable in ordinary cases, to 
wholly exclude nitrogenous food, but it should be restricted, espe- 
cially in regard to eating butcher's meat and eggs, and the evening 
meal should be made very simple, consisting of food such as bread, 
crackers, rice or porridge, and milk. 

Chronic Bright's Disease 

Causation. — Chronic interstitial nephritis may be of primary ori- 
gin, or it may occur as a result of arterio-fibrosis and other condi- 
tions. It is usually a very slow process, and is often provoked by 
chronic alcoholism. 

Urine of a low specific gravity is passed in greater amount than 
normal, and thirst is increased. The arterial walls are thickened and 
their tension is high. 

That an exclusive meat diet is not the cause of chronic Bright's 
disease is proved by the fact that Eskimos and other races, who 
subsist altogether upon it, are not especially liable to the dis- 
ease, although in the long sunless winter they live under very bad 
hygienic conditions. (See the relation of proteid food to albumi- 
nuria, p. 493.) It is nevertheless a fact that the disease is very 
prevalent in this country among men past forty years of age who 
for years have been overworked with business cares, and who have 
neglected to take sufficient exercise and care in eating. In the early 
stages of the disease much may be accomplished by dietetic treat- 
ment. Osier says that " care in food and drink is probably the most 
important element in the treatment of these early cases." 

Whatever views may be entertained in regard to the causation 
of albuminuria, it is agreed by all that cooked meats, eggs, and 
highly seasoned food in general are injurious in all cases of existing 
albuminuria. One should be cautioned against regarding the amount 
of albumin present in the urine from time to time in the course of 
chronic albuminuria as an exact indication of the extent of the renal 
disease. The fluctuations observed are often due to diet merely, and 



THE URINARY SYSTEM 497 

the albumin may occasionally be considerably reduced in quantity, 
or actually absent temporarily from the urine, although the lesion of 
the kidneys is making uninterrupted progress. The volume of albu- 
min in the urine must not, therefore, be estimated alone as an indi- 
cation for dietetic treatment ; it is merely one of many symptoms 
incident to the course of chronic Bright's disease whfch are bene- 
fited by a strict regimen. 

Extensive disease of the excretory surface of the kidneys always 
interferes with the normal elimination of nitrogenous waste matter 
which accumulates in the system until it finally produces toxic or 
ursemic symptoms of a most serious character. If the alimentary 
canal is overloaded with food above the actual requirements of nu- 
trition, or beyond the capabilities of the system for oxidising food 
products, toxic symptoms are sure to follow. For these reasons the 
diet in chronic Bright's disease must be definitely regulated, and a 
mean must be maintained between overburdening the digestive 
apparatus and withholding food which is needed to support the 
bodily strength. This applies especially to the waste of nitrogenous 
food, which passes off through the kidneys, whereas the waste of 
farinaceous food is eliminated largely from the lungs and skin in the 
form of water and carbonic acid. 

Milk Diet. — In many cases of chronic Bright's disease the effect 
of feeding the patient for six weeks, or even two or three months, 
upon an exclusive milk diet is remarkably gratifying. The quantity 
of urine, urea, and extractives increases, while the albumin dimin- 
ishes, and cedema and general anasarca disappear. The patient's 
strength and general condition improve, the pulse is strengthened, 
and if dyspnoea pre-existed it subsides. 

The quantity of milk to be prescribed for an exclusive milk diet 
in Bright's disease must depend on the age and size of the patient, 
as well as upon his ability to take exercise and use up force in 
muscular energy. If the patient is invalided so as to be confined 
to his room or the house, from five to seven pints of milk daily are 
quite sufficient. Seven pints of milk contain 216 grammes of albu- 
min and casein, 172 grammes of fat, and 161 grammes of lactose; 
whereas, according to Pettenkofer and Voit, a healthy adult requires 
137 grammes of dry albumin, 117 grammes of fat, and 352 grammes 
of carbohydrates (see p. 286). The milk diet is therefore deficient 
in carbohydrates, but the latter are estimated in Voit's table for a 
person taking active exercise, and requiring the development of more' 
muscular energy and heat than the invalid. If the patient loses 
weight on a milk diet, although it otherwise agrees with him, it 
may be well to add farinaceous food in the shape of rice or bread. 
Many patients will live contentedly with no other food than a bowl 
of bread and milk four or five times a day. In some cases it is in- 
advisable to commence the milk diet immediately, and a good result 



49$ DIET IN DISEASE 

can be best attained by cutting off one article of solid food after 
another and replacing the loss by an additional tumbler of milk. 
Where it is expected to employ a milk diet for many months, as 
in an advanced case of Bright's disease, it is usually found that the 
milk is better borne if taken fresh at a natural temperature and with- 
out flavouring of any kind. Although the treatment may seem se- 
vere at first, if the patient understands the gravity of the situation 
he is usually willing to accept it, and after a few days seldom com- 
plains of the monotony of this most restricted form of feeding. In 
the worst cases it is desirable to give the milk at brief intervals, in 
quantities of six ounces, once an hour during the daytime, with an 
extra tumblerful at night, and on awakening in the morning. Or- 
dinarily, however, it is tiresome to have to drink milk so often, and 
the quantity may be so regulated as to give the requisite amount 
once every three hours. The quantity of milk necessary to support 
life for any length of time and maintain good nutrition, especially 
if the patient is exercising at all, is considerable, and he must take 
from fourteen to eighteen, or even twenty-two six-ounce tumbler- 
fuls of milk in the twenty-four hours. It is usually impossible to 
commence at this rate without producing gastric disturbance from 
souring of the milk in the stomach, and possibly diarrhoea. The 
latter symptom is an almost certain indication that the milk is being 
imperfectly digested, and a temporary reduction in its quantity is 
advised. 

It is very important to thoroughly cleanse the mouth after drink- 
ing the milk, in order to avoid coating of the tongue and the dis- 
agreeable taste which destroys the appetite and interferes with the 
efficacy of the treatment. For a full discussion of this subject the 
reader is referred to the article on milk diet in typhoid fever (p. 
426). Obstinate constipation, which almost invariably results from 
a long-continued milk diet, must be met by medicinal treatment, or 
the use of glycerin suppositories or enemata. As a rule, the milder 
laxatives are the only remedies necessary ; a glass of citrate-of-mag- 
nesia solution, a half tumblerful of bitter water taken on rising in 
the morning, a drachm of the compound-licorice powder, or a two- 
grain pill of extract of cascara sagrada at night, will prove sufficient. 
There is, however, no objection in most cases to allowing the use 
of a few stewed prunes or the soft part of two or three baked apples. 

It will be observed that whereas the normal average quantity of 
urine for an adult male is fifty-two ounces for the twenty-four 
hours, the milk diet under discussion requires the ingestion of up- 
ward of one hundred ounces of fluid. This necessitates greatly in- 
creased activity of the kidneys, but the polyuria usually results in 
the removal of the anasarca which frequently exists. The body 
weight may remain normal, or even be slightly increased on this 
treatment. It is not infrequently diminished, however, but much 



THE URINARY SYSTEM 499 

depends upon the condition of the patient at the time when the 
milk diet was inaugurated. The abundant urine is of a pale-yellow- 
ish hue, which is somewhat typical of the milk diet. The specific 
gravity is low, and the reaction may be neutral or faintly acid on 
account of the great dilution of the fluid. The albumin, which at 
first may be present in considerable bulk — sufficient when coagu- 
lated to almost solidify the contents of the test tube — gradually 
diminishes, and the urea and salts increase. In mild cases this 
milk diet should be continued from four to eight weeks, after 
which a slight variation may be allowed in the shape of farinaceous 
food, fresh vegetables, and fruit, such as oranges and lemons. In 
other cases it may be necessary to prolong the treatment for half 
a year or more, because it will be found that any attempt to mate- 
rially alter the diet is followed by an increase in the albumin and 
dropsy, with return of other symptoms. In such patients the lesion 
of the kidney is far advanced and incurable, and the most that 
can be hoped for from any treatment is an amelioration of the worst 
symptoms, and it is found that in many cases this can be best se- 
cured by milk diet. For the class of cases in which this treatment 
is found for any reason to be impracticable, either from the persist- 
ent refusal of the patient to take milk or from any other cause, be- 
fore giving up its use efforts should be made to modify its prepara- 
tion in various ways, tempting the patient with different flavours 
and with light farinaceous foods, of which milk forms an important 
basis, such as bread and rice puddings. A good deal of milk may 
be taken in very weak coffee or tea, or in the form of soups and 
purees made with celery or potatoes, or gruels may be given, or 
milk thickened with tapioca, vermicelli, sago, or rice, and flavoured 
with a little lemon or orange peel, cloves, or allspice. It is not 
desirable to use much high seasoning for fear of irritating the dis- 
eased kidneys. 

As the patient improves, the milk diet may be given up, but it 
should never be too suddenly abandoned. A sudden restriction of 
fluids in chronic nephritis is always injurious. In adopting any 
other diet it is a good rule never to let the nitrogenous food bear 
a greater proportion to the non-nitrogenous than one to four. The 
former increases the proportion of urea in the urine ; the latter 
reduces it. A purely vegetable diet has often been tried for albu- 
minuriacs, but it causes too pronounced anaemia if its use is per- 
sisted in, and a minimum of animal food must therefore be pre- 
scribed. Granger Stewart says, in speaking of the very chronic 
albuminuria of Bright's disease, " In the more advanced stages the 
diet should be as nutritious as possible, and then certainly fresh 
meat is by no means injurious." Vegetarianism should never be 
persisted in if the patient continues to lose weight and strength. 

When, after a milk diet, the change is to be made to a more 



500 DIET IN DISEASE 

liberal menu, the hours of taking the milk may be reduced in fre- 
quency, and some of the milk may be replaced by boiled fish, 
chicken, or game, and fresh green vegetables, potatoes, cream, but- 
ter, and bacon. Cereal foods may be eaten ad libitum, such as 
hominy, corn bread, oatmeal, sago, tapioca, rice, vermicelli, bread 
pudding, and macaroni. Cheese may be eaten occasionally. The 
urine should still be periodically examined, and if it is found that 
the eating of meat is followed by an increase in the albuminuria 
the patient must return to the milk diet. 

It not rarely happens that strict adherence to a milk diet for 
several months produces more lasting improvement in the action 
of the kidneys, so that a diet to which steak, roast beef, chops, and 
eggs are admitted may not only be well borne, but may increase the 
strength of the patient. This is a matter which obviously cannot be 
regulated by fixed rules. If the general principles of the treatment 
are understood, it is within the province of any intelligent physi- 
cian to apply them to individuals. In cases in which it is found 
after trying all methods that milk cannot be assimilated in any form, 
the patient must live upon a carbohydrate diet, consisting of fresh 
vegetables and fruits, with butter, cream, and olive oil. Dujardin- 
Beaumetz allows pork and ham to be eaten by those who refuse 
to relinquish meat entirely. Cheese is to be avoided. 

Senator believes that whenever serious albuminuria is present 
Qgg albumin and meat should be withheld, although a little fish or 
flesh poor in albumin, like that of chicken or veal, may be given if 
necessary, but he prefers to prescribe only vegetables, salads, and 
fruits, or an exclusive milk diet of two litres per diem. 

Semmola recommends the use of the following drink, which 
may be mixed with milk, and which possesses a decided diuretic 
action : 

Sodium iodide 15 grains. 

Sodium phosphate 30 " 

Sodium chloride 90 " 

Drinking water 36 ounces. 

In general, the patient had better leave alcohol alone, especially 
in the form of malt liquors. If habituated to its use, a feeling of 
dulness and drowsiness after a glass of wine is a strong reason for 
giving it up. An occasional " spree " may do the patient less harm 
than continued drinking in smaller quantity. For a non-alcoholic 
subject, if weak and anaemic, as he improves, a little light wine or 
claret diluted with Seltzer water or Apollinaris may be ordered as a 
beverage. Tea, coffee, and cocoa are permissible. 

The effect of dietetic treatment will be much enhanced by secur- 
ing systematic outdoor exercise, and freedom from worry and anx- 
iety, and particular attention must be paid to keeping the bowels 



THE URINARY SYSTEM 501 

open, for which laxative fruits may be taken freely. The patient 
must be cautioned against overeating, and all food must be thor- 
oughly masticated. 

PYELITIS 

Most cases require abundant fluid, such as alkaline mineral 
waters, for the purpose of washing out the pelvis of the kidney, and 
if there is much irritation or painful micturition, it is well for the 
patient to be put on an exclusive milk diet after the manner de- 
scribed above for treatment of nephritis in the preceding section. 



OXALURIA 

The condition of oxaluria may be unsuspected by the patient, 
or it may attract his attention by a sensation of burning in the 
urethra, desire for frequent micturition, headache, " nervous- 
ness," etc. 

Causation. — The occasional presence of a trace of calcium oxa- 
late in the urine need not be considered as abnormal, but the con- 
tinued presence of this substance in excess is mainly caused by eat- 
ing certain kinds of food and by dyspepsia and perverted nutrition, 
involving incomplete oxidation in the system of starchy, saccharine, 
and fatty foods. 

Ellis says that " oxalic acid is very readily prepared in the 
chemical laboratory by the action of reagents upon sugar, starch, 
and cellulose. This fact would seem to render probable the possi- 
bility of its formation from the imperfect oxidation of these sub- 
stances in the body," especially from bacterial fermentation in the 
alimentary canal. 

Fliigge has shown that bacteria can form this acid, and its crys- 
tals occur in the intestine and are often found in the faeces. Oxa- 
luria is common in connection with dyspepsia, and it is not 
altogether improbable that some of it may be derived from imper- 
fect digestion of food in the intestine, and be absorbed into the blood 
just as ptomaines are. 

Cantani finds that oxaluria is frequently present among those 
who indulge too freely in saccharine and amylaceous foods. Beneke 
holds quite an opposite theory, and attributes the condition to im- 
perfect metabolism of proteid foods. Even fasting animals may 
still show traces of calcic oxalate in their urine, and both in- 
creased and diminished oxidation have been held accountable for 
oxaluria. 

Vegetables and fruits containing oxalic acid and its salts, and 
which may cause oxaluria when eaten in excess, are rhubarb, toma- 
toes, turnips, onions, sorrel, spinach, figs, strawberries, apples, 
pears. Many other fruits and vegetables contain traces of oxalic 



502 DIET IN DISEASE 

acid, but this fact is of little or no dietetic importance. Raw fruits 
and vegetables which contain citric, malic, and other organic acids 
seem to bear close relation to the formation of oxalic acid. The 
latter is not necessarily ingested with the food, but is produced in 
the body from a variety of substances. 

Dietetic Treatment. — The diet should consist of animal food — 
fish, poultry, game, and meat — with stale bread or toast with a 
minimum of butter. Tea, coffee, carbonic-acid water, and alcohol 
should be temporarily forbidden. Hot water (three quarters of a 
pint) should be sipped half an hour before each meal, and before 
breakfast a drachm or more of Carlsbad salts may be taken in con- 
stipated cases. Dilute mineral acids, hydrochloric or nitro-hydro- 
chloric, are beneficial if taken immediately after meals in doses of 
fifteen or twenty minims in water. 



CALCULI, RENAL AND VESICAL 

Beverages. — When the presence of vesical calculus has been 
demonstrated it becomes important to regulate the diet so as to 
prevent, if possible, aggravation of the trouble. Not much is to be 
hoped from the action of any solvents, such as the alkaline waters 
or lithia salts, upon a large stone already formed, but diuretics may 
certainly do much to prevent recurrence of the formation by con- 
trolling vesical catarrh, and the production of mucus which forms 
the nucleus, and sometimes a considerable part of many stones. 
As White observes : " Our object should then be to make the urine 
as bland and abundant as possible, and for this purpose there is 
nothing better than milk and the free use of water between meals. 
The particular kind of water to be used is of minor importance, as 
the most noted waters in the treatment of stone seem to have 
purity as their chief recommendation." 

The still spring waters, such as Poland, Londonderry, or Bed- 
ford, may be prescribed, or the waters of Vichy, Saratoga, or Ems, 
on the principle that many patients will drink more fluid which 
bears the name of some reputed " Spring " than they will if it be 
plain water. 

Paget was fond of trying the effect of an exclusive milk diet 
before advising lithotomy. The milk is soothing, and while it is a 
good diuretic, it lessens the desire for frequent micturition which is 
often such an annoying symptom of vesical stone. 

The occurrence of vesical calculus in children is believed by 
Cadge, White, and others to be directly proportional to the diffi- 
culty of getting abundant milk. It is therefore much commoner 
among the children of the poor. White believes that '" diet and 
regimen, at least in cities, have much more to do with the produc- 
tion of stone than heredity, climate, water, soil, etc." 



THE URINARY SYSTEM 503 

Young infants should not "be given lime water indefinitely with 
their milk. 

It is best for adults to relinquish the use of alcoholic stimulants, 
but if this is not feasible light Rhine wine or still Moselle is ad- 
missible, especially if neutralised by some alkaline table water 
(Yeo). Lager beer is not harmful, and a little dry champagne or 
a light hock or white wine may be taken. All the heavier clarets, 
Burgundy and sweet wines of every sort, port, sherry, strong beer, 
ale, porter, and stout are forbidden. Weak tea and coffee may be 
drunk. Only such beverages should be allowed as contain no free 
acids and no sugar, and those having the greatest diuretic effect 
are the best. 

Foods. — All highly seasoned and irritating articles, like vinegar, 
pickles, strong condiments, such as mustard, should be rigidly for- 
bidden, as well as anything prone to excite acid dyspepsia. 

Among patients who have calculi of various kinds a consider- 
able number are at the same time afflicted with obesity. Such per- 
sons must be especially abstemious in regard to the use of fats and 
sugars. Less corpulent persons may be allowed a little more laxity 
in this regard. 

Other substances to be avoided are puddings made with eggs 
and sugar, and containing rice, sago, or other farinaceous foods, 
suet puddings, pastry of all kinds, meat fat, and fat pork. 

Bread, oatmeal, hominy, cracked wheat, cornmeal bread, cus- 
tards, blancmange, boiled fish, and eggs are all admissible. 

In many cases total abstinence from animal food for a week or 
ten days is followed by marked improvement, the patient living 
meanwhile on green vegetables, salads, and cooked fruits which are 
not too acid, such as apples, not sweetened, but flavoured with some 
bland aromatic, like cinnamon, nutmeg, or cloves. In other cases 
it may not be necessary to withhold meat completely, but it should 
always be taken in moderation, not more than once a day, and it 
should be rare, lean, and thoroughly masticated. White meat of 
chicken may be eaten. 

The Carlsbad dietary, in which butter and sugar in all forms are 
rigidly proscribed, is found to benefit calculus cases even more than 
the total withdrawal of meat. 

The above directions apply to the treatment of most varieties of 
calculi, and not to any one kind alone. 

In elderly people, in whom such disorders are relatively com- 
mon, the functional elimination of waste from the body is consider- 
ably impaired. For such persons, as well as for those who live 
sedentary lives, it is important to abstain from overeating and espe- 
cially from the use of animal food in excess. 



34 



504 DIET IN DISEASE 



LITH^MIA— URIC-ACID DIATHESIS— GRAVEL 

Symptoms. — Lithsemia is a condition in which the blood con- 
tains an excess of uric acid or its salts, and is usually productive of 
such symptoms as insomnia, vertigo, tinnitus aurium, disagreeable 
fulness of the head, and general " nervousness." The urine be- 
comes loaded with nitrogenous waste. 

When uric acid appears in excess as a sediment in the urine it is 
very desirable that its formation should be checked, if possible, and 
that any crystals already deposited in the kidneys and bladder 
should be dissolved and eliminated. If the accumulation continues, 
the presence of crystals (" gravel ") gives rise to attacks of renal or 
vesical colic, causing intense agonising pain, and often haematuria. 
A majority of the different forms of calculi are composed wholly or 
in part of uric acid, and they may be formed in any part of the 
urinary system, which, in addition to the other symptoms, may pos- 
sibly cause ulceration and inflammation of the mucous membrane 
or serious obstruction to the outflow of the urine. The exact mode 
of production of uric acid in the body is still a matter of uncertainty, 
but it is undoubtedly associated with nitrogenous metabolism, and 
the acid is an imperfectly oxidised form of nitrogenous material. 
The final destination of uric acid is its conversion into urea, but 
from lack of perfect oxidation in the tissues this process is checked. 

Dietetic Treatment. — The indications for dietetic treatment are 
clearly, therefore, to reduce the animal foods in amount or tem- 
porarily withhold them altogether, while giving large quantities 
of plain water and of waters containing potassium or lithium salts 
to aid in dissolving the uric acid already existing in the kidneys or 
bladder, and promote its conversion into urea and hippuric acid. 
The same rules apply to renal inadequacy from any cause, especially 
to lessen the quantity of nitrogen consumed. 

Although the acidity of the urine is not caused by uric acid, but 
by acid sodium phosphate (Na 2 P0 4 ), the deposition of uric acid is 
accomplished in an acid menstruum, and it is well to reduce the 
urine temporarily to a neutral or even somewhat alkaline reaction. 
This can be done by adapting both food and drink. 

Animal food, except milk, tends to make the urine acid, whereas 
milk and vegetable food favour alkalinity. In speaking of the lithic- 
acid diathesis in children, Fothergill wrote that " lean meat, raw 
meat minced, and beef tea are so much poison." Lithsemic head- 
aches will often cease when the patient stops eating butcher's meat, 
cheese, etc., if excessive indulgence in animal food has been the 
previous habit. Peptonised food is worse, for the dyspepsia which 
often accompanies lithsemia is in a way a conservative process, 
checking the digestion of animal foods, whereas the predigested 
foods are more promptly and easily carried to the overburdened 



THE URINARY SYSTEM 505 

liver. Some lithaemic patients cannot take meat well in hot weather, 
but can do so at other seasons. But an excessive meat diet cannot 
be regarded as the sole cause of lithaemia ; other factors are con- 
cerned, such as overeating and the abuse of saccharine food, which 
causes malfermentation, deranges the functions of the liver, and 
alters the composition of both blood and urine. 

Murchison declares that " habitual lithaemia often results from 
the patient taking more food than can be converted into tissue or 
disintegrated in the liver," and Sir Henry Thompson expressed his 
views in regard to sweets thus forcibly : " Sugar, in all its forms, at 
every meal, and wherever met with, forbid it altogether, ... let 
fatty matters, butter, cream, and the fat of meat, whether simply 
cooked or in combination to form pastry, be taken very sparingly." 
This is the practice at Carlsbad also, and it reduces the work of 
the liver and kidneys. For some patients — especially the obese — it 
is more important than wholly eliminating meat from the regimen. 

Murchison, who was among the first to advocate a rational die- 
tetic treatment of habitual lithaemia, forbade all saccharine and 
oleaginous food, especially " made dishes," and highly seasoned 
foods, sauces, rich gravies, etc. In severe cases he advised giving 
up amylaceous foods as well, and forbade the eating of potatoes, 
rice, sago, fruits, etc., and bread was allowed only in moderation. 
In most cases, however, vegetables were given sparingly, and white- 
fish, poultry, game (if not too rich), and eggs were included. The 
total quantity of food was reduced. 

Many acids contained in fresh fruits, such as benzoic or quinic 
acid, have a favourable solvent action. These acids are found in 
the external cuticle of fresh fruits and vegetables, which may be 
eaten in cases of gravel. According to Lyman, eating raw, unpeeled 
apples in considerable quantities supplies potassium salts, which 
tend to increase the alkalinity of the blood, but sweet fruits, pears, 
grapes, plums, strawberries, etc., must not be indulged in. 

Patients may eat abundantly of oatmeal, wheaten and Graham 
bread toasted, macaroni, fresh young peas, string beans, Lima 
beans, rice, spinach, asparagus, celery, lettuce, and other salads, 
except tomato (without oil). Meat should not be eaten oftener 
than once a day. Fresh fish, sweetbread, poultry, and game may 
be taken sparingly. No diet can be rigidly enforced in every case 
alike. Alexander Haig (Diet and Food) classifies as " uric-acid- 
free " foods, milk and its products, breadstuff's, cereals and glutens, 
nuts, vegetables, and fruits. 

If lithaemia is present in young children after three or five years 
of age, they require a larger proportion of fat. They may have 
bread and butter with a little fat bacon, or a baked potato with 
butter, and puddings of bread, crackers, rice, or sago, but not of 
raw flour. They must not be offered sweets. They have poor ap- 



506 DIET IN DISEASE 

petites, and some variety must be prescribed, or they will lose 
weight and strength. 

Some writers are disposed to attach less importance to dietetic 
errors as influencing lithsemia, and the cooking is far more im- 
portant than the composition of the food. Reasonable variety, in- 
cluding proteid food, should be allowed, for " lithaemics do best on 
plenty of well-prepared food in the greatest variety according to 
the seasons " (L. C. Gray). 

Beverages. — Various alkaline mineral waters are constantly pre- 
scribed for adults, and patients who can afford to take the course 
are benefited by the baths of Carlsbad, Vichy, Neuenahr, Ems, etc., 
but for those to whom travel is an impossibility and whose means 
do not allow them to purchase artificial mineral waters, very good 
substitutes are to be made by dissolving sodium carbonate or so- 
dium phosphate in soda water or sour lemonade, or in plain water, 
in the proportion of from one to two drachms in three or four pints, 
to be taken in the course of the twenty-four hours, or two to five 
grains of the carbonate of lithium may be employed in the same 
way. Effervescent lithium tablets are now sold which may be added 
to a tumbler of water at the table and taken with meals. 

Solution of the deposits, or at least the prevention of their in- 
crease, is aided by the free drinking of Londonderry, Buffalo, or 
other lithia waters, Vichy, Waukesha, etc., although it must be 
said of most so-called lithia waters that their use is chiefly that of 
pure water, for a barrelful would have to be drunk to obtain an 
ordinary medicinal dose of lithium. 

Most patients do better without alcohol in any form. They may 
feel the loss of accustomed stimulation for a few months, but they 
should make a strong effort to give it up completely. Malt liquors 
and sweet wines, champagne, and spirits had better be absolutely 
forbidden, but if necessary, a little good sound claret or Scotch 
whisky in water may be drunk. 

Gravel is much less common among habitual beer drinkers than 
among those whose daily beverage is wine. This is attributed by 
Moleschott to the greater acidity and larger proportion of alcohol 
in the latter. On the contrary, Ebstein holds that beer is not in- 
jurious in lithiasis, and tea also has some reputation in checking the 
deposition of uric acid. Coffee does no harm. 

Gonorrhoea 

The dietetic treatment of gonorrhoea consists in avoiding all 
alcohol and stimulating food and drinking bland diluents. 

In severe cases, and in cases among young children who have 
in some manner been infected, a skimmed-milk diet should be or- 
dered at first. Later, light farinaceous articles, stale bread and but- 



THE ALIMENTARY CANAL 507 

ter, milk, and rice puddings should be added. Patients, for fear of 
attracting attention to their ailment, are often unwilling to restrict 
their meals, but they must avoid acid fruits, all highly seasoned and 
fried food, condiments, and pastry. Alcoholic drinks in all forms 
are absolutely prohibited. Malt liquors are especially bad, as they 
are in all diseases of the urethra, bladder, or prostate. No late 
meals should be taken. By observing these directions troublesome 
chordee and ardor urinse, so apt to appear in the first fortnight, may 
be prevented. Large quantities of such waters as soda, Seltzer, 
Apollinaris, and two or three quarts of plain water should be drunk. 
The fluid dilutes the urine, diminishes the danger of cystitis, and 
has the additional advantage of decreasing the appetite. 



DIET IN DISEASES OF THE ALIMENTARY CANAL 

Diet in Abnormal Dentition 

In abnormal dentition in children the food is imperfectly masti- 
cated, and gastric dyspepsia or gastric catarrh may follow. If den- 
tition is delayed and the teeth are imperfect, as in the case of rickets, 
scrofula, tuberculosis, or any protracted disease involving nutrition, 
the diet should be made as nourishing as possible, and meat, eggs, 
milk, cream, and broths should be given in addition to cereals. 
Cod-liver oil is usually prescribed with benefit. There is no one 
food of special value for retarded dentition on account of its con- 
taining the lime salts of the teeth, and the chief reliance for this pur- 
pose must be placed in building up general nutrition. 

In all cases of dyspepsia, gastric catarrh, rickets, or syphilis the 
teeth must be carefully examined before prescribing special dietetic 
treatment. 

If the teeth are broken or irregular all solid food should be 
carefully prepared by mincing or otherwise reducing it to a form 
requiring but little mastication. In a young child a sore mouth from 
swollen gums is often overlooked as a cause of anorexia. 

The perfection with which false teeth are now fitted has done 
much to improve the digestion of adults and to add to the comfort 
and, no doubt in some instances, prolong the life of the aged. Their 
use enables solid food to be eaten, and the act of mastication in- 
creases the flow of saliva, which not only digests starchy food but 
tends to neutralise a too acid gastric juice, if the latter be present. 

Catarrhal Stomatitis 

Catarrhal stomatitis is a simple inflammation of the mucous 
membrane of the mouth which, among other causes, may be ex- 
cited by taking food or drink at either extreme of temperature. 



508 DIET IN DISEASE 

Food which is very acid or too highly seasoned with condiments 
mar cause it, so also may excessive drinking and smoking. 

No special diet is required beyond giving food which is easily 
swallowed and which is free from the above objections. 

When the disease occurs in infants their diet must be regulated 
according to the directions for feeding detailed under the heading 
Infant Feeding. 

In gangrenous stomatitis the mouth may become too sore to ad- 
mit of swallowing, in which case food must be given by the rectum. 
(See Nutrient Enemata, p. 408.) Otherwise small quantities of 
fluid food must be ordered at frequent intervals. Concentrated 
meat broths, egg albumin, meat juice, and milk are to be taken at 
hourly intervals. If the stomach is irritable this food should all be 
predigested with pancreatin. Alcohol, preferably in the form of 
brandy, should be frequently given to the limit of toleration. 

The above directions apply also to cases of inflammation of the 
mouth and pharynx caused by corrosive poisons, such as carbolic 
acid, ammonia, etc. 

TONSILITIS AXD QUINSY 

These diseases require no special care in the acute stage beyond 
giving food in such fluid form as can be most easily swallowed. 
The pain caused by this act is often so extreme that it is advisable 
to concentrate all food, to lessen the number of necessary acts of 
deglutition. Meat juice, peptonoids, beaten eggs, and brandy may 
be added to good milk. Plain vanilla ice cream may be given. Its 
coldness is sometimes soothing to the pharynx. 

Holding cracked ice in the mouth before swallowing will some- 
times annul the pain momentarily, or in extreme cases the pharynx 
and tonsils may be sprayed with cocaine, and the period of tempo- 
rary anaesthesia may be utilised for swallowing considerable nour- 
ishment. This is rarely necessary, for unless the patient is ema- 
ciated by previous serious illness, he is not apt to be in need of 
much food for a day or two. In bad cases of suppurative tonsilitis 
the strength suffers more, and stimulants may be given by the rec- 
tum if deglutition is impossible. 

After all forms of tonsilitis there is apt to be considerable anae- 
mia, and the patient for a week or two should eat abundantly of 
animal food. Eggnog and milk punches are often needed for the 
first few days of convalescence. 

Dysphagia 

When the normal mechanism of swallowing the food is disturbed 
the condition is called dysphagia. It is commonly due to one of the 
following causes : Spasm of the muscles of mastication (trismus) ; 



THE ALIMENTARY CANAL 509 

inflammations of the mouth, tongue, pharynx, or tonsils ; diphtheria ; 
tubercular, cancerous, or syphilitic pharyngeal disease ; retropharyn- 
geal abscess ; stricture or carcinoma of the oesophagus ; paralyses 
(sometimes of central origin) ; operations upon or near the pharynx ; 
or the wearing of an O'Dwyer tube in the larynx. 

The devices employed to enable the patient to overcome pain or 
difficulty in swallowing his food should include reduction of the 
efforts at swallowing to a minimum. A raw egg or oyster may 
sometimes be gulped down by a single act when the dread of pain 
from more repeated effort deters the patient from taking other food. 
Whatever is given should therefore consist of concentrated nutri- 
ment in a smooth, semisolid or gelatinous form. Wine jelly may 
be re-enforced with beef peptonoids or tgg albumin, and custards 
may be thickened with farinaceous material to a consistence which 
will enable them to be quickly swallowed. 

When patients are unable to swallow, an oesophageal tube is in- 
serted for feeding, which, however, should be a catheter of small 
calibre (English 8 to 18), and which need not be passed very far 
down into the oesophagus. If necessary, a 2- or 4-per-cent solu- 
tion of cocaine may be first applied to the pharynx to relieve pain 
and irritation. The fluid food — eggnog, broths, thick gruels, milk, 
etc. — is poured into the tube through a funnel. 

When the tube feeding cannot be practised, it becomes necessary 
to resort to rectal enemata, or both methods may be employed in 
order to reduce the number of feedings through the painful throat. 

Delavan calls attention to the important fact that the point of 
greatest irritation is often the palatine arches, and by passing the 
tube through the nose into the pharynx behind them this difficulty 
is neatly avoided. 

In hopeless cases of cancer or of tubercular ulceration of the 
epiglottis, tonsils, etc., which are so intensely painful, it may be 
justifiable to perform gastrotomy in order to place food directly in 
the stomach. This is certainly preferable to letting the patient starve 
to death because he finds the agony of swallowing is even worse 
than the pangs of hunger. 

Stricture and Carcinoma of the CEsophagus 

In diseases of the oesophagus which render swallowing difficult 
all food must be given in semisolid or fluid form. Many vegetable 
substances can be made into purees, which can be strengthened by 
meat extracts, peptonoids, or beef meal. Milk, in its various forms, 
is always soothing, and it may be the only food which the patient 
can take. 

Richardson states that in oesophageal stricture cold food relaxes 
the circular fibres of the oesophagus and dilates its lumen, whereas 



5IO DIET IN DISEASE 

hot food has an opposite effect. In some hysterical patients this 
may prove true, but in most cases of genuine stricture or occlusion 
the temperature of the ingested food makes but little difference. 
When the occlusion or the difficulty or pain in deglutition becomes 
so great that the patient suffers from inanition — as, for example, after 
corrosive poisons have been swallowed — he must be fed by nutrient 
enemata. Should the trouble not be overcome, a gastric fistula must 
be made, and the patient is to be fed by this means. 

Feeding through a Gastric Fistula. — When a gastric fistula is 
made the wound may be left open with a drainage tube, or, what 
is better, a permanent hard-rubber or metallic tube is inserted, having 
a double flange, like a spool. The tube is nickel-plated to prevent 
erosion by the acid gastric juice. The lumen may be a third of an 
inch in diameter, and when not in use it is kept closed by a cork. 
When the patient is to be fed he must lie upon his back. The cork 
is removed, the tube cleansed with a syringeful of warm water, and 
through a glass funnel, to which is attached an inch or two of rubber 
tubing, fluid food and water is poured directly through the fistulous 
opening into the stomach. If desirable, lavage may be performed in 
a similar manner. Any kind of food may be given which the patient 
is able to digest. Even small pieces of chopped meat can be pushed 
into the stomach with a glass rod or forceps. Medicines are con- 
veniently given through the same opening. When the fistula has 
been made for other cause than, malignant disease the tube may be 
worn indefinitely with no other inconvenience than that attending 
the peculiar process of feeding. I have seen several patients who 
have worn such tubes for several years, and who go about like other 
men, excepting that they take their meals in private and feed them- 
selves while lying on the back. One of these patients, who was 
operated upon in Bellevue Hospital by F. S. Dennis for a benign 
stricture of the pylorus following typhoid fever, first masticates his 
food, then expectorates it and pushes it into the tube with a glass rod. 
He maintains robust health. 



FOREIGN BODIES SWALLOWED 

When foreign bodies have been accidentally swallowed, such as 
coins, buttons, safety or other pins, large cherry, plum, or other 
fruit stones, fish bones, chicken bones, or pieces of clam or oyster 
shells, if the patient is seen within two or three hours, the object 
having passed beyond the reach of the finger or oesophageal pro- 
bang, an emetic may be given. If this fails to return the foreign 
body from the stomach, the patient should eat large quantities of 
bread, oatmeal, or potatoes. The plan of this treatment is to fur- 
nish a bulk of faecal matter, which in the intestines may envelop 
the pin or bone, and prevent its sharp or roughened ends from in- 



THE ALIMENTARY CANAL 5 1 1 

juring the mucous membrane. Six or eight hours later a dose of 
castor oil should be given. By this means many dangerous objects 
may be safely voided. If the foreign body does not appear after 
the oil has acted, the treatment should be repeated next day, and 
the stools must be carefully watched until it is recovered. Experi- 
ence has shown that the search should not be abandoned for at least 
eight or ten days. Men who earn a precarious livelihood by publicly 
exhibiting themselves as possessing " iron stomachs," and who swal- 
low broken glass, coins, nails, etc., take considerable risk from ex- 
citing grave injury or peritonitis, but by eating the foreign bodies 
only when the stomach is nearly full, and by following the treatment 
outlined above, they manage to escape death. 

Indigestion and Dyspepsia 

Symptoms. — Indigestion and dyspepsia are terms which refer 
essentially to functional slight and often temporary derangement of 
the digestive system, although these conditions may result from 
many varieties of disease, especially from fever due to almost any 
cause. The terms are used somewhat vaguely to include a number 
of minor symptoms, such as weight and oppression at the epigas- 
trium and prsecordium, eructations, " water brash," palpitations, ver- 
tigo, headache, modified taste and thirst sensations, loss of appetite 
or morbid craving for certain indigestible articles of food, flatu- 
lency, hiccough, and sometimes nausea, heartburn, pain referred to 
the cardiac end of the stomach, lassitude, irritability, drowsiness or 
restlessness, and despondency. As Sir Henry Thompson said : " The 
word indigestion denotes not a disease, but an admonition." 

Fothergill wrote : " If it were not for the protection of indiges- 
tion, of which many so bitterly and ungratefully complain, the lives 
of a large number of individuals would not attain their furthest po- 
tential expansion." 

Many of these symptoms, especially those referable to the nerv- 
ous and vascular systems, are explained by the belief that morbid 
products which closely resemble poisonous alkaloids in their action 
(as indeed in their composition), and which are called ptomaines or 
leucomaines, are easily absorbed, and produce effects varying in 
intensity from slight headache to the collapse of violent ptomaine 
poisoning (p. 374). Other symptoms are doubtless due to imperfect 
elimination of waste matter of food or " ashes " from the system. 

Bauer says : " It is beyond doubt that insufficient secretion is the 
essential cause of most dyspeptic symptoms as they appear in vari- 
ous disorders of the stomach." 

In severe fevers and conditions of advanced anaemia or gastric 
catarrh the stomach secretes chiefly a ropy alkaline mucous fluid, 
with little or no true gastric juice. 



512 DIET IN DISEASE 

As a rule, the acid gives out before the pepsin, and a deficiency 
of acid is a very common condition, especially in anaemia. Anaemia 
produced experimentally by repeated bleeding of animals will 
cause it. 

Chronic hyperemia and inflammation of the stomach excited by 
coarse irritating food have the same result, and the free acid, if 
secreted, is neutralised by abundant mucus. 

Deficiency of hydrochloric acid in the gastric juice has a three- 
fold effect: i, Failure to digest proteids ; 2, failure to arrest mal- 
fermentation or putrefactive changes in the food ; 3, failure to excite 
gastric peristalsis, so that the food lingers too long in the stomach. 
Other causes of delay may be found in too large a bulk of food, 
lack of peristalsis, and obstruction through stenosis of the pylorus 
without corresponding increase in contractile power of the stomach. 

Gases. — The normal gases of the stomach are those of atmos- 
pheric air; but food which is improperly fermenting is capable of 
evolving others, and those which have been determined by analysis 
of eructations are C0 2 ,H 2 ,0 2 N 2 ,CH 4 (marsh gas) C 2 H 4 (olefiant 
gas). Ewald reports a case in which sufficient marsh gas was evolved 
from the stomach to burn with a pale-yellow flame. 

Some degree of lactic-acid fermentation may be a normal accom- 
paniment of gastric digestion, but the process is easily carried too 
far ; butyric acid develops, and gases are evolved. This action re- 
sembles that produced outside the body when decomposing albumin 
comes in contact with saccharine substances. 

Distention of the stomach and intestine with gas interferes with 
the free play of the diaphragm in the respiratory movements, and 
since the heart lies upon its side, separated from the stomach only 
by the diaphragm, an inflated stomach compresses and displaces the 
heart, interfering with its rhythm and force and causing palpitations. 
The latter, in connection with impeded extent of movement of the 
diaphragm, produces dyspnoea, especially on exertion. 

Pain is a very frequent accompaniment of dyspepsia. It is usu- 
ally of a dull aching variety, but is sometimes sharp and acute. It 
is often erroneously referred to the heart, but it is due rather to 
hyperesthesia of the stomach wall, excited by products of imperfect 
digestion. 

In all diseases of the stomach the retention of any particles of 
undigested food gives rise to irritation and malfermentation, which 
still further complicates the diseased condition of the organ itself 
and interferes with its proper action upon fresh quantities of food. 
This may be occasionally relieved by vomiting or by the ingestion 
of some simple fluid which will aid in washing the stomach contents 
onward into the intestine. 

Etiology, Idiosyncrasies. — Personal idiosyncrasy is a very potent 
factor in dyspepsia. Not only do individuals vary from one another 



THE ALIMENTARY CANAL 513 

in this regard, but the same person varies at different periods, in 
different stages of health, or at different ages. One not uncom- 
monly observes persons who are most confirmed dyspeptics at home, 
but who when at sea are able to eat and digest all manner of richly 
cooked and thoroughly indigestible food without either nausea or 
discomfort, only to return to their dyspepsia on shore. On the other 
hand, many persons whose digestion is normal at home are made 
constipated and dyspeptic by the lack of exercise and by other con- 
ditions at sea, even though they be never " seasick." How often 
do dyspeptics who have been long kept upon a rigid regimen break 
away from all restraint and give astonishing accounts of the for- 
bidden articles which they have suddenly discovered they can eat 
for a time with impunity ! One who cannot digest the most tender 
mouthful of prepared meat or a crust of dry bread will thrive upon 
enormous quantities of nuts and oranges ; another requires a pre- 
posterous quantity of pickles or of Cayenne pepper to stimulate the 
sluggish digestion into any sort of activity, and another lives largely 
upon raw apples ! 

Many people cannot eat strawberries without attacks of heart- 
burn, dyspepsia, and angina, while for others they are very whole- 
some food. Some persons cannot eat cauliflower without exciting 
dyspepsia, and for others the use of melted butter invariably brings 
on such an attack, while butter spread upon bread does not. Others 
exhibit intolerance for twice-cooked meats, new bread, potatoes, 
sweet jams of any kind, etc. (See Idiosyncrasies in Regard to Food, 

p. 39I-) 

Other Causes. — Fats and greasy foods set up butyric-acid fer- 
mentation which causes heartburn, regurgitation, and a rancid dis- 
agreeable taste. 

Sweets and raw or insufficiently cooked starches cause lactic-acid 
and other fermentations, with flatulence. 

Combinations of certain foods almost always disagree, as, for 
example, sweets and acids, fruits and beer, ice cream and beer, milk 
and cherries, milk and crabs. 

Dyspepsia is often caused by the continued abuse of irritants, 
such as alcohol and highly seasoned food, pickles, mustard, Cayenne. 

Tobacco and strong tea and coffee have a depressing action upon 
the nervous force of the stomach. 

To enumerate all the various substances which may at some time 
or other cause indigestion would be to include practically the entire 
list of foods. Each new case must be separately studied, and gen- 
eral rules admit of many exceptions. 

Balfour concisely sums up the relations of food to enfeebled 
stomach digestion by saying : " Three things greatly disturb gastric 
comfort — too large a meal, too short an interval between the meals, 
and, lastly, the ingestion of food into a stomach still digesting." 



514 DIET IN DISEASE 

Examination of the Patient. — It is important at the outset to 
understand all the patient's habits of daily life, the amount of sleep 
and exercise taken, the hours of meals and quantity and quality of 
food eaten, habits of drinking or smoking, the habit of the bowels, 
condition of the stools, and the nature of any irregularity — the habit 
of eating too fast or taking too much or too little fluid with the 
meals. The condition of the teeth and tongue and breath must also 
be observed, and in obscure cases the possible existence of sources 
of reflex irritation, like ovarian disease, must be investigated. The 
proper cooking of the food should be insisted upon. Thorough 
cross-examination in regard to all of these conditions may reveal 
habits not suspected by the patient to be injurious, and which may 
be easily corrected. 

Slow Eating. — A simple explanation of the normal physiology 
of digestion will often interest an intelligent patient and secure his 
hearty co-operation in methods suggested for his cure, which other- 
wise he would find extremely irksome. He should understand that 
digestion commences at once in the mouth by the proper preparation 
there of all food and the digestion of starch in particular, and that 
the practice of slow eating gives time not only for more thorough 
mastication, but also for more abundant secretion of the neces- 
sary digestive fluids, saliva, and gastric juice. Very slow eaters 
are far less often dyspeptic than those who " eat and run." 
The sign " Quick Lunch," so commonly displayed in restaurants 
in business quarters of active American cities, has contributed 
much toward earning for Americans the title of a " Nation of 
Dyspeptics," for a meal quickly served is too quickly eaten as 
well. A dyspeptic child should be taught to count between his 
mouthfuls. 

Solid food insufficiently masticated passes into the stomach too 
dry and in too large masses for the gastric juice to act upon it 
promptly, and stomach digestion is greatly retarded. In persons 
with feeble digestive power who eat hastily, pieces of meat and 
tough vegetable fibres often appear in the stools wholly unaltered. 
The sense of taste may be utilised in order to prolong mastication 
by savoury cooking. It also stimulates the secretion of saliva and 
gastric juice. In such cases, as well as in those in which the teeth 
are absent or defective, it is well to prohibit all food which is not 
completely subdivided or tender, as, for example, tough meats and 
stringy or fibrous vegetables. 

Pain. — In nervous dyspepsia pain exists as a prominent symp- 
tom, and is often independent of the quality of the food — even a 
mouthful of water may cause it, but, as a rule, fatty and acid foods 
excite it, and must therefore be avoided. The appetite, too, varies 
greatly — it may completely fail at one time, and return in an exag- 
gerated form at another. Decker reported the case of a patient who 



THE ALIMENTARY CANAL 5 1 5 

was uniformly awakened from sleep by such excessive hunger that 
he was obliged to take a hearty luncheon in the middle of the night. 

EXAMINATION OF THE STOMACH CONTENTS 

In all cases of protracted dyspepsia which do not yield readily 
to dietetic treatment and proper medication it becomes important 
to ascertain the exact condition of the stomach and gastric juice, 
and for this purpose several ingenious clinical tests have been de- 
vised. These tests are applied to ascertain — I. The degree of acid- 
ity of the gastric juice. 2. The vigour of peristaltic action of the 
stomach wall. 3. The rate of absorption from the mucous mem- 
brane. 

To determine the acidity of the gastric juice, a fresh specimen 
must be obtained for analysis, and by far the best method is by 
siphonage. The stomach tube is inserted in the manner described for 
gastric lavage (p. 538), and the contents of the stomach are with- 
drawn in sufficient quantity to yield a satisfactory analysis. 

Some hysterical dyspeptics vomit so readily that the gastric juice 
may be obtained from the ejecta at any time. 

TEST MEALS 

The composition of the gastric juice is best determined by fol- 
lowing lavage by a test meal. After a definite period the stomach 
tube is again introduced and a sample of the stomach contents is 
withdrawn, filtered, and examined for hydrochloric acid and pepsin. 
If desired, other tests may be made for rennet ferment, carbohy- 
drates, peptones, albuminoses, lactic acid, phosphates, and fatty acids. 
The test for hydrochloric acid is the only one commonly applied 
for clinical purposes, and to aid the selection of proper diet, the 
others belong rather to special research. 

The best test meals are Riegel and Leube's test dinner, and a 
modification of this, known as Ewald's test breakfast, which is easier 
to eat and does not obstruct the stomach tube, although it stimu- 
lates the digestive activity of the stomach somewhat less. The stom- 
ach contents should be withdrawn for examination one hour after 
the breakfast, but between four and five hours after the dinner. 

Riegel and Leube's test dinner consists of — 

Beef soup . 400 cubic centimetres. 

Beefsteak 200 " 

White bread 5° " 

Water 200 " 

Ewald's test breakfast is 35 to 70 cubic centimetres of wheaten 
bread (one or two white coffee rolls) with 300 cubic centimetres of 
water or weak tea without sugar or milk. When the contents of 



516 DIET IN DISEASE 

the stomach are withdrawn one hour after ingestion of this meal 
its total quantity should be found reduced to 20 to 40 cubic centi- 
metres. 

In withdrawing the contents of a stomach after a test meal the 
same tube is used, and in the same manner as that employed for 
lavage, described on p. 538. It is important that its introduction 
should not be accompanied by violent retching, for when this takes 
place bile is very apt to be regurgitated into the stomach and neu- 
tralise its acid contents, rendering subsequent tests useless. The 
retching may be overcome by painting or spraying the pharynx with 
a 2- or 4-per-cent solution of cocaine, or, as Stewart recommends, 
by allowing the patient to swallow a few drops of the solution, to 
anaesthetise the oesophagus. The use of a rather stiff tube, quickly 
inserted, diminishes the liability to retching. The tube should not 
be lubricated when used for the test meals, but it may be wetted. 
The gastric contents may be forced out through the tube by direct- 
ing the patient to forcibly expire, thereby compressing the stomach 
by the abdominal muscles, and simultaneously the epigastrium should 
be firmly compressed by the hands. It is also obtained by attaching 
to the stomach tube the bulb of a Davidson syringe or a suction 
bottle such as that in common use for aspirating the thorax or abdo- 
men. If no fluid flows, a little air or warm water may be forced 
through the tube to cleanse the obstructed fenestra. 

Dujardin-Beaumetz gives a test breakfast of coffee or tea with 
milk and a little sugar, and one or two plain rolls ; no butter. The 
fluid must not exceed a pint. The normal stomach digests such a 
meal without sensation. If within two hours there is a sensation of 
heat in the stomach or burning and acidity, hyperacidity is present. 
If there is eructation of gas, fulness and weight at the stomach, 
then there is diminished or hypoacidity. 

If pain occurs within fifteen minutes with increasing intensity 
there is probably some organic lesion. In hyperacidity, moreover, 
Beaumetz says that the burning is worse three to four hours after 
eating, and is commonest in the middle of the night. It is often 
relieved by ingestion of food, which temporarily dilutes the acid. 
He urges dyspeptics to sleep on the right side, to aid the passage 
of food through the then dependent pylorus. 

TEST FOR TOTAL ACIDITY OF THE GASTRIC JUICE 

Before testing for the presence of free hydrochloric acid, the 
total acidity of the stomach may be obtained, which is the combined 
acidity produced by HC1 and lactic or other organic acids commonly 
developed by malfermentation. This total acidity should equal nor- 
mally 40 to 65 (Ewald), which represents "the number of cubic 
centimetres of test solution required to exactly neutralise 100 cubic 



THE ALIMENTARY CANAL 517 

centimetres of gastric filtrate " (D. D. Stewart). The test solution 
is prepared as follows : 

" Four grammes of NaOH dissolved in one litre of distilled water 
is used for neutralisation ; each cubic centimetre of this solution will 
exactly neutralise 0.00365 gramme of absolute hydrochloric acid. 
The number of cubic centimetres so used multiplied by 0.00365 
equals the percentage of HC1 contained in 100 cubic centimetres 
of the gastric filtrate " (Stewart). 

CHEMICAL TEST FOR FREE HYDROCHLORIC ACID 

A number of chemical tests have been devised for the detection 
of hydrochloric acid. 

Giinzberg's Test for Free Hydrochloric Acid. — 

Phloroglucin 2 

Vanillin I 

Absolute alcohol 30. Mix. 

Two or three drops of this solution are placed on a white por- 
celain dish and allowed to slowly flow in contact with a similar 
quantity of filtered gastric juice. The dish is very slowly and gently 
heated over a spirit flame or Bunsen burner, and if hydrochloric 
acid is present, a faint rose-red hue appears at the line of contact, 
which deepens as evaporation continues into a brilliant cherry 
red. If the acid is abundant, minute cherry-coloured crystals will 
form. If the acid is feeble, it is best to concentrate the stomach 
filtrate upon a water or sand bath to about one tenth of its origi- 
nal bulk. 

When merely a faint trace of the free acid is present the appear- 
ance of the colour should be carefully watched, for it is very eva- 
nescent. 

Gunzberg showed that one drop of the normal gastric juice — i. e., 
juice containing 0.2 per cent of free hydrochloric acid — when diluted 
ten times, should still give the colour. If it appears when the dilu- 
tion is carried beyond this limit, hyperacidity is present. 

This is, on the whole, the most reliable clinical test which has yet 
been devised, and the ease and quickness of its application for diag- 
nostic purposes has much to recommend it. It requires no special 
skill, and should always be made, to test the progress of the treat- 
ment, while lavage is being performed. 

The Boas Test for Hydrochloric Acid. — The Boas test is performed 
in a similar manner to the Gunzberg test, but the colour produced 
varies from rose to vermilion, and the solution is made as follows : 

Sublimed resorcin 5 

Sugar 3 

Dilute alcohof. 100. Mix. 



518 DIET IN DISEASE 

Both tests are only of value from a positive standpoint — i. e., if 
the colour reaction occurs, free hydrochloric acid is surely present, 
They are, however, of little or no value as negative tests, for the 
reason that if peptones or certain other substances are present in the 
stomach contents the reaction may be entirely obscured. The latter 
difficulty is met by application of the calcium-carbonate test, which 
is uninfluenced by other substances likely to be associated with the 
gastric juice, with the single exception of an excess of acid phos- 
phates. 

The Calcium-carbonate Test. — This is conducted as follows : A 
sample of gastric contents is heated to remove fatty acids, and shaken 
with ether to remove any lactic acid present, and blue litmus paper 
is dipped in the fluid. Another blue litmus paper is dipped in a 
fresh sample of the gastric contents which has been neutralised by 
the addition of dry pure CaCo 3 . The redness of the first paper when 
compared with the second will declare the presence of free hydro- 
chloric acid. 

A strong Giinzberg reaction usually indicates normal reaction or 
hyperacidity. Its absence when hydrochloric acid is revealed by 
the CaCo 3 test indicates subacidity. If the latter test fails, then no 
free acid is present. 

Acid Salts. — If the litmus dipped into the gastric juice neutral- 
ised by CaCo 3 is reddened, the presence of acid salts (phosphates) 
is indicated. 

The normal gastric free hydrochloric acid maintains a remarkable 
uniformity in strength, very rarely exceeding 0.2 per cent. 

It has been shown by Ewald and Leo that it is not secreted dur- 
ing fasting, but enters the stomach as soon as the stimulus of food 
is felt. At first it replaces the acids from lactates and phosphates, 
setting these acids free and forming chlorides with their bases. The 
hydrochloric acid also unites with albuminoids. For these reasons 
free HC1 is not apparent in the gastric juice until the combina- 
tions mentioned have been all saturated, after which it increases 
in strength to the normal standard of 0.15 to 0.2 per cent. If 
alkalies are ingested, more HC1 is secreted ; but if acid be taken, the 
further secretion of HC1 is checked, so that the average strength is 
preserved. 

These conditions explain why it is that within fifteen minutes 
after ingestion of an Ewald test breakfast lactic acid may be found 
in the stomach contents, while free HC1 may not appear for half or 
three fourths of an hour. 

Lactic acid is obtainable for an hour, or until the full strength of 
free HC1 secretion is reached. If a heavy meal of bread and meat 
and vegetables has been eaten, the lactic-acid reaction will continue 
for a couple of hours, but free HC1 may not be demonstrated for 
from three to four hours. 



THE ALIMENTARY CANAL 5 19 

This is an observation of considerable practical importance ; for 
in the early stage of digestion, the acidity being low and due only 
to organic acid, the ptyalin digestion of starches still continues, 
but it must cease as soon as any appreciable quantity of HC1 is 
present. 

Free hydrochloric acid checks further development of organic 
acids, such as butyric, acetic, or lactic. The Bacilli acidi lactici fail 
to act in its presence, and other bacilli, like those of typhoid fever and 
cholera, are destroyed by the antiseptic action of the HC1. 

HYPERSECRETION 

Hypersecretion of gastric juice is determined by withdrawing the 
contents of the stomach in the morning after lavage the previous 
evening. If more than fifty cubic centimetres are obtained, hyper- 
secretion may be said to exist, the exact nature of which is to be 
determined by the Gunzberg test (p. 517). Suggestions for the diet 
of such cases are given on p. 525. Gastric atony is determined by 
finding in the morning washing of the stomach undigested particles 
of food eaten the night before. 

The microscopic examination of the washing will exhibit bac- 
teria, sarcinse, and saccharomyces. The treatment of this condition 
is given under Chronic Gastric Catarrh (p. 531) and Dilatation of 
the Stomach (p. 537). ! 

TEST FOR PEPSIN 

The presence of pepsin may be determined by digesting either 
egg albumin or blood fibrin, the latter being preferred. The fibrin 
is whipped from fresh beef blood and washed in water until it be- 
comes white. A small piece is placed in a test tube with fifteen or 
twenty cubic centimetres of filtered gastric juice, and kept at a uni- 
form temperature of 40 C. for two or three hours. If there is 
but little normal HC1 present, a few drops more should be added. 
If no digestion occurs after some hours, pepsin is absent and the 
fibrin will decompose. Quantitative or comparative tests may be 
made by using definite amounts of fibrin and gastric juice, and 
noting the time required for complete digestion. 

TEST FOR RENNET FERMENT 

The presence of the rennet ferment is easily demonstrated by 
adding a few cubic centimetres of the filtered gastric juice to a half- 
teacupful of fresh milk, and keeping the mixture for a short time 
at 40 C. A loose coagulum forms with a limpid yellowish whey 
if rennet be present. 

35 



520 DIET IN DISEASE 



TEST FOR MOTOR POWER OF THE STOMACH 

The motor power of the stomach is demonstrated in various 
ways. 

Leube's Method. — Leube's method is to empty the stomach after 
the ingestion of a Leube's test dinner (p. 515), or Ewald's test 
breakfast (p. 515). If the stomach is empty three hours after 
the former and one and a half after the latter, hypermotility is pres- 
ent — i. e., the food is being too rapidly hurried into the duodenum. 
If undigested food remains six or seven hours after eating the Leube 
test dinner, the motility is impaired, and the diet must be regulated 
accordingly. (See Chronic Gastric Catarrh, p. 531, and Dilata- 
tion, p. 537.) 

Ewald and Siever's Method. — Another method, that of Ewald and 
Siever's. is very simple, but not very reliable. Fifteen grains of 
salol are given in a wafer immediately after a meal, and the urine 
is tested for salicyluric acid, which is derived from salicylic acid 
formed in the alkaline intestine as one of the products of dissocia- 
tion of salol. Salol escapes being acted upon by the gastric juice, 
and the salicyluric acid appears in the urine half an hour or an hour 
after it is sw T allowed if hypermotility be present — otherwise, not for 
several hours. The salicyluric acid is readily detected by the violet 
colour which appears in the urine on adding a drop or two of ferric- 
chloride solution. The chief difficulty in the performance of the test 
is in getting urine when wanted without catheterisation. Frequent 
catheterisation merely for the purposes of such a test is to be con- 
demned, and patients cannot usually micturate every fifteen minutes. 
Brunner and Huber prefer to make the test dependent upon the 
disappearance of all trace of salicyluric acid after ingestion of one 
gramme of salol. Normally it can be detected for only twenty-four 
hours, but if the motor power of the stomach is impaired it may 
be obtained as late as forty-eight hours after. 

Bourget found that the reaction time is delayed an hour or more 
by giving a dose of HC1 with a meat meal, whereas it is accelerated 
by a less acid meal of which fruits and vegetables form a part. 

Stewart, in referring to this experiment, points out that hyper- 
acidity of the gastric juice, by neutralising the duodenal juices, 
might retard the salol reaction without the existence of motor in- 
sufficiency. 

Klemperer's Method. — Klemperer has the patient swallow one 
hundred grammes of olive oil into an empty stomach, or the oil may 
be poured in through a stomach tube. It is left for two hours, and 
then the stomach contents are washed out. The oil is abstracted 
from the washing with ether, and the ether is separated. The oil is 
then measured. Between seventy and eighty grammes of oil should 



THE ALIMENTARY CANAL 521 

pass on into the intestine inside of two hours but if it has not done 
so there is lack of motility. 

TEST FOR ABSORPTIVE POWER OF THE STOMACH 

This test, as devised by Penzoldt and Faber, is very simple. Into 
an empty stomach are taken three grains of potassium iodide in a 
clean gelatin capsule, with a wineglassful of w^ater. 

The saliva is collected at two- or three-minute intervals in sepa- 
rate saucers, and with normal absorption from a healthy stomach 
iodine may be detected in the secretion in from six and a half to 
fifteen minutes, but in gastric catarrh it may not appear for several 
hours. The test is made by dipping a filter paper, previously soaked 
in starch paste, into the saliva, and adding fuming nitric acid. A 
blue colour appears if iodine is present. This test is not very reli- 
able, for if the stomach is full of food the reaction is always much 
retarded, as it also is by fever and in most diseases of the stomach, 
notably ulcer, carcinoma, and dilatation. 

DIETETIC TREATMENT OF DYSPEPSIA 

The foregoing details of the clinical examination of the digestive 
power of the stomach have been given in this connection as a con- 
venient place to summarise them. It is not intended to imply that 
every case of simple dyspepsia should be subjected to so complex 
an examination, but, on the other hand, there are many persons 
afflicted with chronic dyspepsia who waste much time, energy, and 
expense in taking medicines and diet " cures " which are entirely 
unadapted to their particular trouble because it has never been 
thoroughly investigated by the only means which in really serious 
cases permit of an accurate diagnosis. The passage of a stomach 
tube two or three times is all that is necessary for the patient to 
submit to to enable such a diagnosis to be made, and although it 
is never an agreeable process, it is far better than to prolong in- 
definitely a condition of great discomfort, and one which in time may 
develop into much more serious ills. 

The dietetic treatment of dyspepsia is so complex that it is easier 
for some persons to be put upon a very rigidly restricted diet for 
two or three weeks than to have to select for themselves appropriate 
articles at each meal. 

It includes the study of all classes of foods, and for convenience 
they may be grouped into — 

A. Foods forbidden in all cases. 

B. Foods occasionally allowable. 

C. Foods which are desirable. 

A. Foods forbidden in all Cases. — 
I. Rich soups, gravies, and sauces. 



522 DIET IN DISEASE 

2. Strong condiments, pickles. 

3. Fresh soft bread of any kind (which makes a tenacious bolus), 
hot breads, all kinds of pastry, cakes, griddle cakes, doughnuts, 
muffins. 

4. Sweets, tarts, jam, confectionery and candies of every kind. 
Sugar in all forms, especially in coffee and tea with milk. 

5. Raw vegetables, such as celery, radishes, cole. 

6. Heavy vegetables — potatoes, sweet potatoes, corn, peas, 
beans, eggplant, cabbage, cauliflower, Brussels sprouts, turnips, 
carrots, parsnips (nearly all the roots and tubers). 

7. Fat in quantity, all fried or greasy food. 

8. Lobsters, crabs, shrimps, salmon, herring. 

9. Dried, smoked, cured, potted, or " devilled " meats, fish, and 
pork in every form. 

10. Corned beef, duck, goose, wild fowl, rabbit. Veal, except as 
broth. 

11. Twice-cooked meats, hash (unless freshly made, without po- 
tatoes), stews, ragouts. 

12. Cheese of all kinds. 

13. Very acid or very sweet fruits, nuts, dried fruits in general. 
All skins and seeds of fruits. 

14. Tea, beer, and sour wines. 

The excessive use of tobacco in any form should be forbidden. 

B. Foods Occasionally Allowable. — There are foods which may 
be allowed to some patients but not to others, and many of them 
constitute exceptions to the foregoing general rules. Such are : 

Vegetables. — Mealy, well-baked potatoes, not too young or new, 
raw tomatoes, spinach, thoroughly boiled onions, very young tender 
fresh peas, very young Lima beans, string beans, asparagus, stewed 
celery, celery plant (sea-kale). 

Starchy Foods. — Where it is desirable to give starchy food in 
some form, macaroni, spaghetti, or rice may be allowed, or one of 
the prepared foods, such as Carnrick's or Mellin's. All starchy foods 
should be most thoroughly cooked, for salivary digestion is often 
feeble in connection with gastric disorders. 

Fats. — Bacon, very fat, sliced thin and well broiled ; cream, good 
fresh butter, olive oil. 

Eggs. — Many patients find that eggs disagree with them con- 
stantly. There are a few who can take them with impunity if rightly 
cooked — that is, cooked very slowly and soft. They sometimes 
agree better when not given with other food, but as eggnog. 

As a rule, sweet fruits disagree, though they can be eaten by 
some patients. 

C. Desirable Foods to be recommended in Ordinary Cases are : 
Cereals. — Wheaten bread, porous or aerated, stale or toasted ; dry, 

unsweetened rusk or zwieback ; soda crackers. (The bread from 



THE ALIMENTARY CANAL 523 

some bakers is easier of digestion than that from others.) Macaroni, 
sometimes oatmeal, but without sugar. 

Fats. — In moderation only ; butter to be very thinly spread and 
well rubbed in. Sometimes a thin rasher of bacon. 

Vegetables. — Chiefly as purees, thoroughly cooked, made of toma- 
toes, asparagus, or sometimes potatoes or fresh peas. (Fresh green 
vegetables as in preceding list.) Lettuce. 

Fish. — Oysters, fresh-boiled or broiled fish without rich sauces. 
They may be eaten with a little fresh butter and salt. (Some per- 
sons cannot eat fish at all.) 

Eggs. — In any form if they are found to agree (except hard- 
boiled or fried). 

Sweetbreads, Meats. — Broiled steak or chop, tender roast beef or 
mutton, chicken (roasted or boiled), boiled capon, roast partridge, 
grouse, woodcock, plover, prairie chicken, squab. All meats should 
be short-fibred and tender. They need not be very rare. Grilling 
is the best method of cooking them. 

Fruit. — Baked or stewed apples or prunes. Occasionally a little 
fresh fruit in season, better eaten between meals to prevent consti- 
pation. Oranges, peaches, grape fruit. 

Naturally, in bad cases the diet must be still further restricted, 
and a bread-and-milk regimen may have to be enforced until im- 
provement occurs. 

Beverages. — Tea is generally injurious, especially if drunk with 
meals, but weak tea taken clear in very hot water is sometimes 
beneficial by enabling patients to imbibe the , fluid which they need. 
Strong tea is astringent ; it precipitates pepsin and provokes con- 
stipation. Coffee, on the contrary, favours peristalsis, and is mildly 
stimulating to the nervous system. Drunk with milk and sugar it 
often excites dyspepsia and increases flatulency. Taken black after 
dinner it is an adjunct to digestion. If it produces insomnia or 
" nervousness " it should, of course, be discontinued. Yeo says that 
both tea and coffee may cause dyspepsia in those who are under 
mental strain, but not otherwise in the same individual. Light China 
teas are less injurious than the stronger Indian varieties. Coffee 
contains more tannin than tea, which has only a trace. It does not 
itself ferment, but the milk and sugar drunk with it does. 

Cocoa (not chocolate, which is too sweet) may be allowed. An 
infusion of cocoa nibs often agrees. 

Milk and Vichy or milk and Seltzer may be drunk as a beverage 
in non-flatulent cases. 

As a general rule, malt liquors and beers of all kinds must be 
forbidden, although Fagge recommends the use of light, still, bitter 
ale or of porter in some cases ; but he says, " Whatever causes flush- 
ing of the face after meals is bad." Alcoholic dyspepsia is only 
cured by entire cessation of drinking. This the patients are un- 



524 DIET IN DISEASE 

willing or unable to accede to unless very strongly influenced or 
frightened as to the probable outcome of continued indiscretion. In 
simple atonic dyspepsia the use of pure wine, or weak brandy, or 
whisky and water and drunk at meals may prove serviceable. Some- 
times a little dry wine, claret, or hock may be allowed twice a day 
with meals. 

Tobacco, smoked in moderation, in the form of mild cigars or in 
pipes (not cigarettes), promotes digestion by slightly stimulating the 
nervous system and increasing peristalsis. 

Special Systems of Treatment. — The following systems of treat- 
ing dyspepsia are condensed from the writings of several of the 
best-known dietists : 

Dujardin-Beaumetz divides dyspepsia into three classes, and 
regulates their diet accordingly, as follows : 

I. Dyspepsia with abundant gastric juice. Diet, fresh vegetables 
and fruits, farinaceous food, milk, no meat or wine. 

II. Dyspepsia with deficient gastric juice. Diet, meat, broths, 
milk, peptonised food, weak brandy and water. No vegetables or 
saccharine food. 

III. Dyspepsia with sympathetic affections, especially vertigo. 
Diet, purely vegetable food. 

His diet of vegetable food is very liberal, and includes cereals 
as well as fruits. It contains such articles as dry bread crust, toast ; 
farinaceous purees made of one of the following materials : Maize, 
flour, chestnut meal, oatmeal, pearl barley, potatoes, lentils, reva- 
lenta, macaroni (plain or buttered), vermicelli ; purees of fresh vege- 
tables, such as green peas, carrots, turnips ; the vegetables of julienne 
soup ; salads, spinach, sorrel, French beans, fruits, except grapes 
cooked as compote, lightly cooked eggs. 

Germain See's treatment of dyspepsia is exactly the reverse of 
that of Dujardin-Beaumetz. He divides dyspeptics into two classes : 

I. Those who have hyperacidity of the gastric juice, for whom 
he prescribes a nitrogenous diet with sodium bicarbonate after meals. 

II. Those having diminished acidity, for whom he prescribes a 
purely vegetable regimen, with dilute hydrochloric acid after meals. 

He directs in all cases to wash out the stomach and stimulate 
the gastric mucous membrane, for which he orders the alkaline 
sodium bicarbonate in a tumblerful of Vichy an hour and a half 
before eating. 

Leube graduates dyspeptics into four groups according to the 
severity of their symptoms. The diet which he recommends is as 
follows, commencing with the severest cases : 

I. Broth or clear soup, Leube's meat extract, milk, eggs (raw 
or lightly cooked), carbonic-acid water, Apollinaris, or Seltzer. 

II. Boiled calves' brains, sweetbread, breast of chicken or squab, 
bread and milk, custard, unsweetened tapioca pudding. 



THE ALIMENTARY CANAL 525 

III. The same as the two preceding, with the addition of raw 
ham [sic] and rump steak. The latter is strongly beaten, scraped, 
and roasted quickly before a hot fire with a little fresh butter. 

IV. This diet, intended for the mildest cases or for convales- 
cence, includes milk, rice, spinach, roast chicken, partridge, venison, 
rare beef, veal, macaroni, fresh green vegetables, salads, fruit com- 
potes, stewed apples, and light wines. He sometimes allows fish, 
such as bass. 

General Rules for Dyspeptics. — The following general rules are 
applicable to all cases of dyspepsia and indigestion : 

1. Eat slowly, masticate thoroughly. 

2. Drink fluid an hour before or two or three hours after meals, 
rather than with food. 

3. Eat at regular hours. 

4. If greatly fatigued, lie down and rest quietly before and after 
luncheon and dinner or supper. 

5. Avoid as far as possible taking business worries or profes- 
sional cares to the table. 

6. Take systematic exercise in the open air. Bicycle and horse- 
back riding are the best forms. 

7. On rising, cold sponging and vigorous friction of the body is 
advisable. 

8. The bowels should be kept open by laxative foods and fluids 
rather than by medicines. 

9. Avoid too much variety at any one meal. Take meats and 
vegetables at separate meals. 

RULES FOR SPECIAL VARIETIES OF DYSPEPSIA 

Dyspepsia with Excessive Flatulency. — This often occurs in nerv- 
ous women, and is especially annoying at night. 

Avoid particularly all sweets and amylaceous food. Take no 
fluid with meals. Drink hot water, half a pint before meals, and 
again two hours after. Do not eat vegetables and meat at the same 
meal. Try cream instead of milk in coffee, and saccharin instead of 
sugar. Avoid tea and alcohol, especially malt liquors and effer- 
vescing water, with meals. 

Dyspepsia with Hyperacidity. — The diet should consist largely 
of rare finely minced or scraped beef (one hundred grammes, or 
three and a quarter ounces, is ample), with two slices of stale bread 
or toast, or a few crackers with a little butter (thirty grammes). 
Later the patient may partake of the lighter fresh vegetables and 
subacid fruits. Milk may be useful, with 10 grains of sodium bicar- 
bonate to the tumblerful. Vegetables should be thoroughly cooked 
and mashed or made into purees. Fruit must be stewed or, in the 
case of apples, baked. Alkaline Vichy may be drunk. 



526 DIET IN DISEASE 

A few weeks' course of such a diet faithfully adhered to often 
results in cure. 

Dyspepsia with Excessive Nervousness, Irritative Dyspepsia. — 
Avoid tea, coffee, much alcohol, tobacco, stimulating food of all 
sorts, condiments and pickles, and do not overeat. Eat slowly. 
Avoid eating when fatigued or worried. Take one or two extra 
meals a day, if necessary, especially a light one before retiring, to 
promote sleep. (See Insomnia.) 

In the main, vegetable food will be better borne than proteids, 
unless flatulency is annoying. 

Atonic Dyspepsia, Dyspepsia with Deficient Gastric Juice. — Take 
three meals per diem, and freshly cooked meat should be included 
in two of them. Beef, mutton, and poultry are recommended. Meat 
broths and soups, stale bread, toast, or crackers. All meats should 
be tender and simply cooked. 

In purely atonic dyspepsia, with loss of tone in the muscular 
wall of the stomach and sluggish secretion, a diet which is too bland 
and tasteless fails to stimulate the stomach sufficiently, and it is 
better to offer a reasonable variety and a moderate use of condi- 
ments. 

Dyspepsia in the Gouty. — Avoid particularly sugar in every form, 
malt liquors, sweet wines, and champagne. (See Gout.) 

Dyspepsia with Bulimia. — A certain class of dyspeptics are al- 
ways abnormally hungry, for hunger is a general sense, due to the 
needs of the tissues rather than to the purely local condition of the 
stomach. Suffering from indigestion, they fail to assimilate food 
properly, become hungry again soon after meals, and do not obtain 
the full nutritive value of what they do eat. They therefore over- 
eat or eat between meals, and do not give the stomach sufficient 
time for rest. They must be taught to restrain the appetite and to 
stop eating short of satiety to prevent overloading the stomach, and 
a sufficiently long period should intervene between meals for the 
thorough digestion of the food. These patients sometimes have 
hyperacidity. 

Dyspepsia with Anaemia. — Anaemic patients require abundant 
nitrogenous food, and well-seasoned, stimulating meat broths are 
recommended. Such patients may take an extra luncheon or two 
between the regular meals and before retiring. (See Anaemia, 
p. 486.) 

DYSPEPSIA IN CHILDREN 

Children vomit much more easily than adults when they have 
taken improper food, and often suffer less in consequence, although, 
if such food is retained, they may have a gastric fever with a greater 
rise of temperature and, perhaps, more alarming symptoms than 
occur later in life. 



THE ALIMENTARY CANAL 527 

When vomiting occurs in infants the stomach should be rested 
by omitting the next feeding, and for the second feeding the milk 
should be diluted and reduced in amount. If vomiting persists, a 
little bicarbonate of soda or one or two tablespoOnfuls of lime water 
should be added. Other substances, such as gelatin or one of the 
prepared infant foods, may be used to dilute the milk and prevent 
the formation of large curds in the stomach. In obstinate cases it 
may be well to change the diet completely and give up milk for a 
few days. In place of it a mixture may be used consisting of one 
part of cream and two parts each of whey and boiled (not boiling) 
water. 

An overfed infant vomits soon after nursing or taking the bottle, 
and the stools contain milk curds. When an infant receives too little 
food, " the bottle is emptied quickly and ravenously ; the child cries 
when it is taken away, sucks violently at its fingers, and cries before 
the next feeding is due " (Holt). 

Older children should not be allowed to eat between meals, and 
must be forbidden the premature use of coffee, tea, spices, coarse 
vegetables (cabbage, turnips, etc.), and unlimited ice water, fruits, 
and sweets. (See Diet for Infants and Diet for Children.) 



Acute Gastric Catarrh 

Causation. — Acute gastric catarrh is commonly due to dietetic 
errors, although it is also excited in other ways. The dietetic 
causes are : 

1. Food taken in too large quantity. 

2. Food too hastily swallowed or " bolted." 

3. Food in itself irritant or too highly seasoned with sauces, con- 
diments, fats, etc. 

4. Food which has undergone decomposition, such as " high " 
game or fish, overripe cheese, sour milk, or improperly canned 
vegetables. 

5. Alcohol habitually consumed in excess and in concentrated 
form, or a combination of drinking beer and wine or liquor, or 
drinking beer in excess with improper food. 

It may be caused by corrosive poisons. Many individuals appear 
to have special weakness or irritability of the stomach, so that at- 
tacks of gastric catarrh are excited in them by conditions which 
would prove insufficient in others. 

Excessive consumption of food beyond the wants of the system 
and out of proportion to the gastric juice is often an exciting cause 
of gastric catarrh, especially in children. This food need not in 
itself be indigestible. Such cases may result, for example, from 
eating large quantities of meat hash or of ice cream. Favourable 
circumstances are also present in anaemia, nervous exhaustion, con- 



528 DIET IN DISEASE 

valescence from protracted illness, and in fevers, in all of which 
conditions the gastric juice, and especially its hydrochloric acid, 
is apt to be diminished in amount or temporarily absent. In these 
cases digestion is retarded far beyond the ordinary limits, and the 
retained food decomposes by abnormal fermentation, thus becom- 
ing both a mechanical and a chemical irritant to the mucous mem- 
brane. 

Symptoms. — The chief symptoms dependent upon the local in- 
flammation of the stomach are severe vomiting, nausea, pain, weak- 
ness, and fever. 

Dietetic Treatment. — Acute inflammation of any structure is best 
treated by rest, and the stomach forms no exception. Hence total 
abstinence from food and great reduction in the quantity of fluid 
imbibed is often curative after an interval of twenty-four or thirty- 
six hours. The irritation is maintained by ill-advised attempts to 
give food at frequent intervals with the object of supporting the 
strength. The attacks, from the very nature of their causation, often 
occur in robust people who can well afford to forego nourishment 
for a few hours or until the nausea and pain cease. To others who 
have been enfeebled by continued illness or in whom the acute 
attack produces alarming prostration, enemata and stimulants and 
predigested albuminous food must be given. 

The vomiting and nausea are allayed by cracked ice, small quan- 
tities of iced champagne, carbonic-acid w r ater, plain soda water, cold 
lime water sipped in doses of a tablespoonful at a time and at inter- 
vals of fifteen minutes. Strong black coffee is also serviceable. 
These symptoms may also be relieved by hot poultices and turpen- 
tine stupes, or spongiopiline soaked in hot water and sprinkled with 
a few drops of laudanum placed over the epigastrium (Fagge). 

The thirst should not be met by large draughts of water, which 
only distend the stomach and excite vomiting. It may be relieved 
by sucking a piece of sliced lemon or by placing a few drops of 
mineral acid, such as dilute phosphoric or dilute hydrochloric acid, 
in a small tumbler of cold water and sipping it from time to time. 
Thirst may be lessened in some cases by holding water in the mouth 
for a few moments without swallowing it, for a certain amount of 
fluid is absorbed directly through the buccal mucous membrane. If 
large quantities of fluid have been vomited, a simple enema of salt 
and water (fifteen grains to the pint) may be injected into the rec- 
tum, where it is soon absorbed. 

When nourishment is first taken by the mouth, it must be fluid 
and carefully prepared, so that it will either undergo prompt absorp- 
tion or pass into the duodenum for digestion. It must be admin- 
istered only in small doses — half an ounce or an ounce at a time. 
Pancreatinised milk, or cold milk diluted with an equal volume of 
lime water or soda water or alkaline Vichy, milk whey flavoured 



THE ALIMENTARY CANAL 529 

or added to beaten white of egg, beef extracts, peptone solutions, 
black coffee, expressed meat juice, and beef tea properly made, are 
all recommended. Most broths contain too much fat or oil. Milk 
given alone or undiluted soon curdles in the stomach, and is prompt- 
ly ejected in large tough coagulse. Many persons either actually 
cannot digest milk, or more commonly think they cannot, and avow 
a violent distaste for it, declaring that it leaves a perpetual bad taste 
in the mouth and causes headache and nausea. Their experience 
is usually based upon the use of undiluted and unprepared milk, and 
with tact and perseverance they can be got to retain and digest 
prepared milk very well. (See Milk Predigestion, p. 78.) Some 
patients prefer warm milk diluted with water and flavoured with a 
little cinnamon, a taste of coffee or caramel, or they may take barley 
water and rice water. 

If patients cannot drink milk they may be allowed mutton, veal, 
or chicken broths from which the fat has been removed. 

It is best to forbid all alcoholic fluids, even champagne, unless 
the patient is so exhausted that some stimulation becomes necessary, 
in which case brandy diluted with soda water may be given in small 
quantities, or it may be added to beef tea or arrowroot gruel. It is 
important always to aid the recovery of the digestive organs by 
absolute bodily and mental quiet. 

Convalescence. — In convalescence the diet must be very slowly 
increased ; otherwise relapses may follow very easily. After some 
degree of improvement has been reached, the gastric mucus accu- 
mulates with more butyric-acid fermentation, and the vomiting and 
other symptoms return. 

At first but one article at a time should be added to the fluid 
food, gradually replacing it. Broths may be thickened by beaten 
or dropped eggs, crumbled toast, or scraped beef or chicken. Later 
plainly cooked meat, such as broiled tenderloin steak, chicken, a 
tender chop, squab, or a bit of broiled fresh fish with lemon juice 
may be allowed with dry toast and rice pudding. 

It is well to give dilute hydrochloric acid (ten to fifteen drops) 
with two grains of pepsin after each meal. When the illness has 
been very severe the patient must be cautioned to be careful in 
eating for several weeks after the acute symptoms have subsided lest 
a relapse or gastric dilatation occur. Alcoholic subjects will prob- 
ably not heed this warning, but it should be given none the less. 

ACUTE GASTRIC CATARRH— GASTRIC FEVER IN CHILDREN 

Acute gastric catarrh in infants is oftenest due to improper feed- 
ing. It is also excited, or rather promoted, by teething and other 
reflex irritations which interfere with the normal stomach functions. 
There is an acute inflammation of the gastric mucous membrane, 



530 DIET IN DISEASE 

accompanied by more or less fever, vomiting, local pain, and ano- 
rexia. This affection is comparatively rare among nurslings. When 
it does occur in them, the mother's milk should be analysed, and 
any errors in her own mode of life, diet, etc., must be corrected. 
If the breast milk continues to disagree, a wet nurse must be 
procured, and, failing this, the child must be weaned if the disorder 
continues. 

Children just weaned acquire the disease from overfeeding and 
from improperly prepared food, and the number of meals must be 
carefully regulated according to the rules for infant feeding. 

Older children who are allowed to come to table develop the 
disease from eating too rich or stimulating articles, such as pickles, 
sauces, spiced dishes, sweets, pastry, fried food, from drinking large 
quantities of hot or very cold fluid, from eating hurriedly without 
proper mastication, or from gorging themselves with enormous 
quantities of articles of which they are particularly fond, such as 
hash, cakes, etc. 

If seen early, if vomiting has not already occurred and the stom- 
ach is full, it should be emptied by an emetic dose of ipecac. Other- 
wise, if the stomach contents have passed into the intestine, the 
irritating food should be expelled by a laxative, such as calomel or 
grey powder. No food should be allowed for some hours, for it 
will keep up the hypersemia. Nothing should be swallowed but a 
few sips of water or a teaspoonful of cool lime water or a little 
cracked ice. After ten or twelve hours of complete rest the stom- 
ach may tolerate one or two teaspoonfuls of pancreatinised milk or 
milk diluted one half with lime water or Vichy. If this is not re- 
tained, it is better to give a little meat juice or beef broth. The 
next day mild farinaceous food may be allowed, such as arrowroot 
gruel, cornstarch, or farina. Junket also, or milk toast, may be 
retained. It is best to return to a solid diet very slowly and care- 
fully, and such articles as rice pudding, scraped beef, the breast of 
chicken, or the soft part of oysters may be given for a day or two 
longer before the regular diet is resumed. 

For some time after an attack it may be best to reduce the num- 
ber of meals per diem — a child who has been taking five should take 
but four, or one who has had four should take but three. 

Chronic Gastric Catarrh — Chronic Gastritis 

Causation. — Chronic gastric catarrh may be the outcome of such 
errors in diet as have been described as causative of the acute form. 
It commonly results, however, from alcoholic excess. It also accom- 
panies diseases in which the hepatic, and consequently the portal cir- 
culation is obstructed, producing engorgement of the vessels of the 
gastric mucous membrane. It may complicate pulmonary and car- 



THE ALIMENTARY CANAL 53 1 

diac diseases which cause obstruction to the venous circulation. It 
is caused by the severer forms of stomach diseases. 

Pathological Physiology. — Besides congestion of the blood ves- 
sels, which interferes with the maintenance of proper secretion and 
with absorption, the glands of the stomach furnish a hypersecretion 
of tenacious, ropy, alkaline mucus, which clings to the mucous coat 
and prevents the food from exciting the secretion of the gastric 
juice, and it neutralises and prevents the latter from reaching the 
food. The food therefore is retained for hours in an alkaline medi- 
um, where it undergoes maceration and fermentation, which is par- 
ticularly liable to develop large volumes of carbonic-acid and marsh 
gas, which are periodically belched up with such force as to carry 
out the acrid fluid, and even particles of disintegrated food, pro- 
ducing a bitter and nauseous taste in the mouth. The symptom of 
heartburn is due to the eructation of organic acids. The appetite 
is not always lost. It may even be excessive, and it is usually ca- 
pricious. Thirst is often a prominent symptom. Vomiting occurs 
at intervals, especially on rising in the morning, after the gastric 
mucus, mingled with the saliva swallowed, has accumulated during 
the night. 

Dietetic Treatment. — If any improvement is to be hoped for in 
the condition of a patient with chronic gastritis it is absolutely 
necessary to secure the intelligent co-operation of the patient him- 
self by strict obedience to rules which must be made very specific 
and distinct. Many patients will be found to have so little will 
power that, with the best intentions, when they sit at the table with 
others whose good health enables them to partake of all the lux- 
uries of the season they are utterly unable to resist temptation. 

The patient with gastric catarrh should, as far as possible, be 
kept from mental strain and worry or business responsibilities, and 
especially from brooding over his symptoms. A person suffering 
from chronic gastritis often seems to have but a small amount of 
nervous energy to expend, and if too much is diverted in other 
channels, but little is left for the processes of digestion, and gland 
secretion is altered or withheld. It is a matter of every-day experi- 
ence with such persons that when free from all concern and anxiety 
their digestion promptly improves and they can often eat quite in- 
digestible food, whereas much plainer food wholly disagrees with 
them while under mental strain. It is highly important for them 
that meals should be taken with regularity and that abundant time 
should be allowed for mastication. Regular habits, outdoor exer- 
cise, and daily sponge bathing in cold water, followed by active fric- 
tion of the skin, are to be recommended. In forbidding certain 
classes of food, it is often observed that the patient has discovered 
that some one apparently indigestible material can be eaten with im- 
punity, and there may be no harm in allowing this to be continued 



532 DIET IN DISEASE 

in mild cases. Sometimes merely eliminating from the diet such 
obviously indigestible foods as pies, griddle cakes, pickles, fried 
foods, or rich cheese, will produce marked improvement, but it is 
often necessary to enforce a very strict regimen. 

Milk Diet. — Severe cases, especially those complicating Bright's 
or cardiac disease, demand rigorous restriction of the diet, and it 
may become necessary to give milk exclusively for two or three 
weeks. From two to two and a half or three quarts of fresh milk 
are required for this diet in the twenty-four hours, the amount de- 
pending upon the size and weight of the patient and his ability to 
take exercise. The latter, however, must be reduced to a great ex- 
tent while the milk diet is in force. The milk may be given either 
hot or cold, but hot milk is best. It should be diluted with soda 
water or an alkali, such as sodium bicarbonate or magnesia, and 
salt should be added. Very bad cases with extensive atrophy and 
abundant mucous secretion may require pancreatinised milk and beef 
preparations. 

In some cases, especially those due to chronic alcoholism, there 
is annoying thirst, which is relieved by diluting the milk with equal 
parts of Vichy or Apollinaris water. The fluid has the additional 
advantage of increasing the elimination of waste from the system 
through the kidneys. 

To most patients who are ill enough to require a fluid or an 
exclusive milk diet, it is preferable to give food frequently, at the 
rate of four ounces of the above mixture once in two hours, until 
the condition of the stomach improves, when the dilution of the 
milk is to be reduced, given in larger quantity (six to eight ounces), 
and the intervals may be prolonged to three hours. When much 
gastric irritation or nausea exists, the milk, if at all rich in cream, 
should be skimmed, as fat is not well tolerated. Buttermilk is used 
quite extensively in Germany and somewhat in this country for the 
treatment of gastric catarrh. It may be taken undiluted. To some 
persons the taste is more agreeable than that of ordinary milk. 
The casein of the buttermilk is already coagulated and exists in a 
condition of fine subdivision, so that it does not form large clots 
in the stomach. Patients usually tire sooner of buttermilk than of 
plain milk. Milk, no matter how given, is apt to produce consti- 
pation. 

When patients insist that milk always disagrees with them this 
is often on account of their not having the methods by which it may 
be prevented from forming tough coagulse in the stomach, and it is 
worth while to explain this fact to them, and secure their consent to 
give a fair trial to some of the numerous means which may be em- 
ployed for improving the digestibility of this invaluable food (see p. 
75). If there is much dilatation of the stomach, milk is usually con- 
traindicated. 



THE ALIMENTARY CANAL 533 

Other Diet. — Should it prove impossible for the patient to digest 
enough milk to support strength, his diet must be supplemented 
with other articles of food, such as scraped meat or peptonised meat. 
As a rule, the food should be either fluid or almost entirely solid ; 
drinking considerable fluid with solid food dilutes the feeble gastric 
juice too much for proper digestion. No broth or soup should be 
allowed with meals. Alcohol should in general be forbidden, and 
tea, coffee, or cocoa are to be taken only in moderation, much di- 
luted, and without milk and sugar. Occasionally light wine, such 
as hock and Moselle, may be given, but effervescing wines are 
forbidden. Fluids should not be taken too cold. 

Oysters may be allowed either raw, broiled, or panned. Butter 
may be allowed very sparingly, and cream sometimes, but in gen- 
eral fats and oils should be avoided as well as all fat meats, pork, 
sausages, and solid food cooked in grease. Rich gravies and sauces 
of every kind must be forbidden, and all solid food must be thor- 
oughly masticated. Many persons, especially those who have an 
excessive secretion of hydrochloric acid, live best on a diet of lean 
roast beef, rare steak, or white meat of chicken, eaten with stale 
white bread or dry toast and very little butter. This diet can be 
taken for some time before serious objection is made to its mo- 
notony. 

One occasionally meets with persons in whom the digestion of 
salt and smoked meats seems to be more easily accomplished than 
that of fresh meat. The explanation offered by Niemeyer is that 
these preparations are less likely to decompose and form abnormal 
fermentation products in the stomach. Dried smoked beef, cut in 
thin slices and eaten almost or quite raw, is palatable and easily 
digested. Some dyspeptics can also digest lean boiled ham, lean 
smoked bacon, and salt fish, such as shredded codfish, thoroughly 
cooked, better than they can fresh meat. Leube allows caviare, 
smoked ham, and boiled lean veal. Sweetbreads and calves' brains 
are digestible. Tough meat and flesh of young animals recently 
killed, such as " bob " veal, must not be eaten. 

Fish and soft-cooked eggs disagree w T ith some persons, but others 
can digest them without difficulty. 

Saccharine and farinaceous foods are to be avoided. Sooner or 
later they are almost certain to undergo lactic and butyric-acid fer- 
mentation in the stomach with the production of much eructated 
flatus and " sourness." When improvement is established, the pa- 
tient may gradually be allowed a little carefully prepared starchy 
food, but still no sweets of any kind. A single lump of sugar in a 
cup of cafe an lait drunk at breakfast can produce an acute dyspep- 
sia, lasting all day. The varieties of starchy foods which may be 
first eaten are those which have been thoroughly subjected to the 
heat of baking or long boiling. Such are : Dry bread thoroughly 



534 DIET IN DISEASE 

toasted, bread crust, plain crackers, zwieback, gruels or meat soups 
thickened with arrowroot, thoroughly cooked sago, or ground rice, 
vermicelli, and macaroni well boiled. The purest carefully baked 
wheat bread from hard white wheat flour agrees better than the 
coarser varieties of brown bread, whole-meal breads, etc. 

Many persons who take an intelligent but not hypochondriacal 
interest in their digestion find by repeated trial that the bread of a 
certain baker agrees with them, while that of another does not, 
although its nutritive value for normal stomachs may be the same 
in both cases. 

Potatoes are apt to produce flatulency with sour eructations, and 
when this is the case they must be forbidden. If roasted and very 
mealy they may be sometimes allowed. Among vegetables those 
which are especially forbidden are cabbage and cauliflower, the leg- 
umes, and corn. A little fruit may be allowed between meals, such 
as cooked apples, either baked or stewed, or stewed prunes, if not 
too sweet. 

Especially forbidden are pastry, sweets of all sorts, sweet pud- 
dings and cakes, griddle cakes, hot breads, pickles, fried foods, and 
strong condiments. 

In all cases of chronic gastric catarrh it is important to reduce 
the bulk of food taken so as to diminish the liability of its remain- 
ing in the stomach undigested. Food which is so selected and pre- 
pared as to diminish the work of the stomach should be given only 
at long intervals in order that the digestion of one meal may be 
thoroughly accomplished before the next is eaten. It is well to 
order at least six-hour intervals between the meals, and they should 
not be eaten too soon after exercise. 

Convalescence. — As the patient improves, the dietary may be 
somewhat enlarged, and thoroughly cooked fresh vegetables, such 
as spinach, celery, asparagus, onions, and fresh young peas, may 
be added. 

Fresh ripe fruit will be found serviceable in curing constipation, 
which almost invariably follows as a result of concentrated diet. In 
many cases this trouble must be counteracted by the daily morning 
use of some aperient, and a half tumblerful of hot Hunyadi water, 
or of Friedrichshall bitter water, or a drachm of Carlsbad salts in a 
tumbler of hot water, should be taken each morning before any food 
is swallowed. The salts are further serviceable by diminishing hy- 
persemia of the stomach and hepatic engorgement. Much benefit is 
derived from drinking a glass of hot water or a glass of hot Vichy 
from half to three quarters of an hour before each meal, the object 
being to separate the layer of thick ropy mucus which overlies the 
orifices of the gastric tubules. Much of the advantage to patients 
with chronic gastric catarrh received from a course of treatment at 
Carlsbad and similar spas is due to the action of sulphate of soda 



THE ALIMENTARY CANAL 535 

and other alkalies in removing mucus from the stomach and cleans- 
ing the membrane beneath, rather than to any specific virtue in the 
salts themselves. 

Hydrochloric Acid. — The value of hydrochloric acid given to aid 
digestion consists quite as much in its power to promote the con- 
version of pepsinogen into active pepsin as to act directly upon the 
food. The latter can be accomplished very well by artificial digestion 
outside of the body. If therefore there is complete atrophy of the 
gastric tubules in chronic gastric catarrh of long standing, the giving 
of the acid fails to excite secretion from tubules permanently de- 
stroyed, and Boas declares that the acid combines so readily with 
the salts and albuminoids of the food that it is not practicable to 
give enough of it to have any free acid remaining, and he only 
recommends it for those cases where the function of the gastric 
tubules, as shown by testing the digestive power of a sample of the 
stomach juice, is not wholly abolished. He admits its usefulness as 
an antifermentative. This view is not generally held, however, and, 
as a matter of practical experience, the majority of these cases are 
improved by taking dilute hydrochloric acid with any solid animal 
food which is allowed them which is otherwise found to cause dis- 
comfort. It is best to give the acid not immediately with the food, 
but half an hour later, and twenty minims may be prescribed in one 
dose, or two or three doses of ten or fifteen minims may be given 
at intervals of half an hour. It may be prescribed alone in half an 
ounce of water, or mixed with a little glycerin in a claret glassful of 
water, and it should be swallowed through a glass tube to save the 
teeth from injury. 

Exercise, Massage, Lavage, etc. — Exercise should be recom- 
mended, but so regulated as not to interfere with digestion. It 
should be postponed until digestion has been in progress for at 
least an hour or two, and, when the patient's strength admits of it, 
gentle horseback or bicycle riding and moderate rowing is bene- 
ficial for the young and middle-aged. 

Massage of the stomach, performed two hours after meals, is of 
service, and lavage is of great value when pyrosis and gastric dis- 
tress occur so soon after eating as to indicate active malfer- 
mentation. 

Daily morning douching of the stomach to remove mucus and 
muco-pus in those in whom a dyspeptic tendency exists will serve 
to prevent the advent of chronic catarrhal gastritis (D. D. Stewart). 
This process, which is fully described in connection with the treat- 
ment of Dilatation of the Stomach (p. 537), is now much less in 
vogue than formerly for simple gastric catarrh. 

Saline laxatives and appropriate tonics, such as strychnine and 
arsenic, are indicated in addition to the dietetic measures above de- 
scribed. 

36 



536 DIET IN DISEASE 

Electricity is of service only when one pole of the battery is in- 
troduced into the stomach by Einhorn's method (p. 542). 

In obstinate cases change of scene and occupation may do much 
good, and a sea voyage is sometimes to be suggested. 

CHRONIC GASTRIC CATARRH IN CHILDREN 

Children with chronic gastric catarrh should always eat their prin- 
cipal meal in the middle of the day, and take only a light supper. 

When of nervous temperament, they are apt to bolt their food 
without proper mastication. At the age, too, when their deciduous 
teeth are being replaced they may from time to time have difficulty 
in eating solid food. This matter should be inquired into, and if 
necessary all such food must be minced before it is given to the child. 
Children accustomed to luxury usually overeat, and suffer in con- 
sequence. Their supervision at table is often left to ignorant or 
careless servants, who should be cautioned, and better heed will be 
taken if the instruction is given by the physician rather than by an 
indulgent mother. 

In young children gastric lavage is easily performed, and it may 
be beneficial, but older children are apt to struggle and resist it. 
The tube may be passed as in gavage (see Gavage), and directions 
for lavage are also given on p. 538. For this purpose it is well to 
use only water which has been previously sterilised by boiling. 

Dilatation of the Stomach — Gastrectasia 

Causation. — Dilatation of the stomach may result from stricture 
of its pyloric end, or from chronic gastric catarrh, in which case it 
is accompanied by the secretion of much tenacious mucus. The 
stricture may be due to a carcinomatous growth, to hypertrophied 
mucous membrane caused by chronic gastritis, or to contracture 
following gastric ulcer. 

Gastric dilatation is also produced by loss of tone or paresis of 
the muscular coat, by destruction of the muscular coat due to ulcer- 
ation, and by lack of proper nervous or nutritive supply, such as 
results from debilitating illness, like typhoid fever, tuberculosis, or 
general nervous prostration. Less often it is caused by abuses of 
diet, especially those which give rise to much gas by excessive use 
of effervescing beverages, etc. The varieties due to gastritis, de- 
bility, and dietetic errors are most amenable to treatment. 

Pathological Physiology, — The food is improperly digested, 
owing to want of gastric juice and of peristalsis or to admixture 
with quantities of mucus. It therefore lingers in the stomach be- 
yond the usual time, ferments, interferes with thorough digestion 
of the next meal, and renders the chyme unfit for the intestine. 
Food will often lie undigested in a dilated stomach all night, and 



THE ALIMENTARY CANAL 537 

be vomited with accumulated mucus in the morning. The undi- 
gested food accumulates, and by its weight drags down the stomach 
and favours further dilatation by stagnation and development of 
gases. The motor function of the stomach is almost completely 
suspended, and the organ must therefore be taxed as little as possible. 

Dietetic Treatment. — For these reasons it is necessary to limit 
the quantity of solid, and especially of fluid nourishment. Nothing 
but the simplest articles of diet should be allowed. All food should 
be given in a concentrated and readily assimilable form, so that 
it will either be absorbed directly from the stomach wall or pass 
promptly into the duodenum. 

In bad cases food should be predigested as much as possible, 
although many of the predigested foods are open to the objection 
that they are much diluted in the process, and are therefore less 
serviceable. The more concentrated varieties should be chosen. 
Ewald recommends the employment of peptonised condensed milk, 
which is very nutritious and of an agreeable flavour. It should be 
condensed without addition of the usual excess of cane sugar, which 
will surely ferment in the stomach. 

The patients are often thirsty, and, in fact, the original dilatation 
may have been caused by excessive imbibition, but the amount of 
fluid drunk with meals must be restricted to four or six ounces, or 
in bad cases no fluid at all should be allowed at mealtimes. If the 
thirst is considerable, a tumblerful of hot water may be taken a half 
hour before meals, to be absorbed or pass into the intestines before 
the food enters the stomach. Water is more quickly absorbed hot 
than cold. In bad cases thirst may be relieved by water enemata, 
but they are rarely necessary. 

The proper diet for gastric dilatation is the same as that recom- 
mended for chronic gastritis, except that it is even more concen- 
trated and smaller in bulk, and farinaceous food is almost wholly 
forbidden. 

At first only animal food should be given, such as scraped beef 
or a piece of broiled chicken, with perhaps a very little dry toast or 
toasted cracker. If vomiting is a persistent symptom, Petrequin 
advises the patient to drink milk very slowly, taking crushed ice 
with each mouthful. Later, after from two or three to six weeks, 
if improvement has resulted, more latitude is permissible, and the 
food advised is lean meat free from coarse fibres ; fresh vegetables, 
young peas, asparagus, tomatoes, tender and well-cooked purees, dry 
bread, haricots, lentils, lettuce or cress with vinegar, simple starches, 
such as sago, macaroni, rice, tapioca, and vermicelli, boiled or 
broiled oysters or fish, soft-cooked eggs, orange juice, stewed or 
baked apples without sugar, stewed pears. Some patients may drink 
a tumblerful of boiled milk between meals, but, as a rule, it is best 
to take nothing. Some dietists recommend a perfectly dry diet, 



538 DIET IN DISEASE 

omitting all fluids, and order three meals a day at long intervals. 
In mild cases, coffee and tea without sugar are allowed. 

To be avoided are most forms of starchy food, and sugar, pota- 
toes, old peas, beans, corn. Fruit consists largely of water in pro- 
portion to its nutritive value, and its vegetable acids are apt to 
disagree. It must therefore be eaten sparingly. Fats, butter, and 
oils are not digested in the stomach. Thirst-exciting foods, as salt 
fish, must not be taken, nor beer, effervescing mineral waters, red 
wine, thin soups, milk, water, tea, coffee, diluted or light alcoholic 
beverages. 

In all cases too long continuance of a very rigid diet is liable to 
cause the patient or the stomach itself to rebel. The patient should 
be weighed once a week. The stools must be examined and the 
general nutrition carefully considered. If weight is rapidly lost, the 
food, whatever it may be, is not being assimilated, and it should be 
changed. It may become necessary to disregard the rules for fluid 
and put the patient for a time upon a diet of prepared milk. 

Aids to Dietetic Treatment. — Other means of treatment which 
are really adjuncts to dietetic measures should be recommended. 
Such are lavage, massage, and electricity, which will be considered 
below. Mucus, especially that which is accumulated overnight, may 
be washed out of the stomach by sipping a cup of very hot water 
or taking alkaline mineral water, or a pint of water with ten grains 
of bicarbonate of soda, on rising. 

It is often desirable for the patient to lie down for an hour and 
a half after eating, and he should especially avoid mental and bodily 
fatigue, which tend to divert both nerve energy and the blood from 
the functions of digestion. 

Hydrochloric acid and pepsin mixtures with the nitrogenous diet 
are serviceable. 

Lavage. — In cases of either dilatation or catarrh of the stomach 
which fail to improve on restricted diet and other methods of treat- 
ment lavage or stomach washing becomes necessary. This is an 
entirely safe procedure, and one to which patients become readily 
accustomed, provided sufficient tact and care is employed when the 
method is first applied. It was first practised by Kussmaul in 1867. 
The operation met with so much success that it has since that time 
been generally adopted, and it is perfectly easy to perform with a 
little experience and care. It should be attempted in all serious cases 
in which other methods to relieve the patient have been already 
tried and have failed. It is almost indispensable in those cases in 
which the atony of a greatly distended stomach wall prevents the 
food from being expelled into the intestine, causing constant accu- 
mulation and fermentation, or in cases in which decomposing food 
passes into the duodenum, exciting intestinal dyspepsia, meteorism, 
and diarrhoea. 



THE ALIMENTARY CANAL 539 

As many as sixteen varieties of bacteria have been obtained from 
the washings of a dilated stomach in which food had been stag- 
nating. 

The advantages of lavage are twofold ; it not only removes irri- 
tating and fermenting material from the stomach, and the ropy, 
tenacious mucus which it contains, and allays vomiting, but the 
water itself applied to the mucous membrane cleanses it and stimu- 
lates the gastric glands to normal secretion and the stomach wall to 
contraction. It also promotes more regular action of the bowels. 

The relief from the sensations of weight, oppression, discomfort, 
and nausea which is promptly experienced after lavage is usually 
immediate and lasts for several hours. It is so great that patients 
not infrequently learn to pass the oesophageal catheter themselves, 
and, holding a pitcher of warm water in one hand and a funnel in 
the other, they wash and siphon out their own stomachs with ease. 
Usually it is sufficient to wash the stomach once a day. In extreme 
cases it may be necessary to perform the operation twice a day, but 
when improvement is once established, washing may be limited to 
every other day or may be employed occasionally, according to 
need, but it should be continued for several weeks after the sub- 
sidence of all symptoms. As a result of this treatment, the stomach 
may diminish in size, and the food is always better digested and 
more completely absorbed, while nutrition and assimilation are cor- 
respondingly improved. 

The best time for digestion of the principal meal of the day is 
within an hour after each lavage, when the stomach is empty and 
thoroughly cleansed, and the meal can often be assimilated com- 
pletely. If decided repugnance to food exists, the tube may be 
used for forced feeding, and peptones and predigested milk may be 
poured in before it is withdrawn from the stomach, although, as a 
rule, it is best that too much fluid food should not be given. 

In performing the operation of lavage a medium-sized oesopha- 
geal tube should be selected, about one third of an inch in diameter, 
having two or three large smooth eyes or " velvet " fenestra and 
made of good, smooth red rubber which is sufficiently flexible with- 
out being so easily bent as to allow the tube to double upon itself 
in its passage. This tube should be fully eighteen inches long, and 
it is attached to a length of three feet of common rubber tubing by 
means of a small glass tube ; the other extremity of the rubber tubing 
is fastened to a funnel through which warm water is poured into 
the stomach. A glass funnel is preferred, which makes it easier to 
examine the washings as they return. The patient is cautioned to 
keep the head straight forward and thrown back and not to bite the 
operator's finger, and the tube is gently pushed over the dorsum 
of the tongue down over the posterior pharyngeal wall into the 
oesophagus. The insertion of the tube will be facilitated by oiling 



540 DIET IN DISEASE 

it slightly with a little olive oil, butter, white vaseline, or glycerin, 
but white of tgg or milk are less likely to nauseate. 

If there is any difficulty in introducing the tube, its downward 
passage may be aided by passing the forefinger to the back of the 
pharynx. If the patient, who either sits or stands, is instructed to 
make an effort at swallowing while the tube is being inserted it 
will descend much easier, and pains should be taken to explain the 
process and reassure him, for nervousness and struggling may excite 
spasms of the laryngeal muscles and make it difficult or impossible 
to pass the tube. On reaching the cardiac end of the stomach, the 
tube is occasionally stopped for a moment, but the patient should 
be instructed to try and swallow, and with gentle pressure the ori- 
fice soon relaxes and the tube enters the stomach. Or a little water 
poured into the tube may cause the cardia to relax. The funnel is 
raised above the patient's head, but before pouring in much fluid it 
should be ascertained that he is able to breathe comfortably and 
quietly when the tube is momentarily compressed. He should be 
reassured that he will not choke. Accidents have occasionally hap- 
pened from passing small tubes down into the larynx, and I have 
known of one fatal case in which a nasal tube was thus passed and 
milk was poured into the lungs. A case has been reported in which 
beef tea was poured into the lungs in this manner, but the patient 
recovered and the beef tea was coughed up or absorbed. There is 
very little danger of introducing an oesophageal tube of the or- 
dinary size in the wrong direction, for any attempt to push it into 
the pharynx will be met by obstruction and spasmodic coughing. 
If the stomach is full when the tube is first passed, some of the 
contents may be immediately siphoned out by lowering the funnel 
below the stomach level and holding it over a foot tub or pail. If 
necessary, water can be poured in gently to the extent of a quart, 
or until the patient complains of uncomfortable fulness in the stom- 
ach. Care should be exercised not to admit air bubbles. The tube 
and funnel are then inverted over a foot tub or wash basin and the 
contents of the stomach are quickly siphoned out. This operation 
may be repeated a number of times until all the food and mucus 
have been removed and the washings return quite clear and neutral 
in reaction. 

The quantity of water used in the washing should be measured 
so that it all may be siphoned out again, as it is undesirable to leave 
any fluid behind. 

When the tube is introduced for the first few times it may excite 
efforts at vomiting, but it is not necessary to remove it, for the 
patient can usually regurgitate the long, stringy mucus alongside 
of it. Salivation is often produced in the first few trials. After one 
or two attempts patients will learn to swallow the tube themselves 
with very little assistance and cease to gag upon its introduction. 



THE ALIMENTARY CANAL 541 

If there is hyperesthesia of the pharynx the pharyngeal wall may 
be touched with a 2- or 4-per-cent cocaine solution just before the 
introduction of the tube, or several large doses of bromide of potas- 
sium may be administered during the previous twenty-four hours. 
If nausea occurs when the tube first reaches the cardia it is usually 
overcome by pouring in a little fluid. The success of the opera- 
tion at the first trial depends largely upon the skill of the physician 
and the degree to which he has obtained the confidence of his 
patient, and has been able to overcome any nervous feeling in re- 
gard to a process which is at best highly disagreeable. After the 
sufferer from gastric dilatation has experienced the relief which 
lavage of the stomach can give, he usually requires no urging to 
allow the process to be repeated. In withdrawing the tube it should 
be compressed in order to avoid having any of its contents trickle 
into the larynx. 

The fluid used for washing the stomach may be either cool, 
warm, or quite hot water. Warm water is best, but it is well to 
sterilise it by previous boiling. If much mucus is present or much 
acidity, sodium bicarbonate may be added in the proportion of two 
or three per cent (15 grains to the pint), or a similar quantity of 
sodium borate or boric acid, a one-half-per-cent solution of salicylic 
acid, or a i-per-cent solution of sodium salicylate. Vichy is occa- 
sionally used. 

The best time for conducting lavage is shortly before the midday 
meal, the patient having had a very light breakfast, and it should 
only be performed when the stomach is believed to be compara- 
tively empty. If the tube is introduced before breakfast, having 
had nothing to eat for a number of hours, patients are more apt to be 
disagreeably affected, especially if the washing be long continued, 
and I have occasionally seen them become faint under these circum- 
stances. It is better, therefore, that a light breakfast of bread and 
milk, pancreatinised milk, or of a scraped-beef sandwich and a cup 
of black coffee should be taken ; three hours later the stomach is 
to be washed. There are exceptional cases in which the patient is 
so distressed by the effort to pass the tube or by the operation of 
rinsing the stomach itself that it has to be abandoned. Lavage 
must be avoided in cases complicated by much prostration, feeble 
heart action, aneurism, hsematemesis, or haemoptysis. 

Accessory measures which are to be used in connection with 
lavage and careful regulation of diet are massage and medicinal 
treatment which consists largely of the administration of tonics, 
especially strychnine, with the object of increasing the muscular 
action of the stomach. This remedy may be given hypodermically 
if necessary. 

Massage. — Gastric massage should be performed about two and 
a half or three hours after each meal for ten minutes. The patient 



542 DIET IN DISEASE 

must lie upon his back, with knees drawn up and muscles relaxed. 
The movements, stroking and kneading, must be always made over 
the stomach in the direction of the pylorus, the object being to 
facilitate emptying the stomach through that opening, and to stimu- 
late peristalsis. If not too weak, the patient may be taught to per- 
form these movements himself. This treatment is often of consid- 
erable aid in mixing the food and gastric juice and in propelling the 
food into the intestine. It increases peristalsis. 

Electricity. — Faradisation of the stomach is believed by many 
to increase its muscular tone, and various forms of electrodes have 
been devised for this purpose. It is probable that very little, if any, 
electric stimulation reaches the stomach when currents of ordinary 
strength are applied over the epigastrium, although Ewald and 
Sievers claim that it does in some cases. This is especially true of 
faradism. Canstatt first proposed to apply the current directly 
within the stomach wall, and methods have been devised by Bardet, 
Einhorn, and others to serve this purpose. 

The ingenious electrode invented by Einhorn, of New York, is 
easily passed into the stomach. It consists of a hard-rubber cap- 
sule about the size of a small French olive. The hollow capsule 
has numerous perforations and within it is a small metallic elec- 
trode. The capsule is fastened to a fine flexible conducting wire, 
which is attached to the battery, and the wire is protected by a 
minute soft-rubber tube one inch in diameter. This electrode is 
readily swallowed by placing it upon the dorsum of the tongue and 
then drinking water. About forty centimetres of the wire should be 
swallowed. In withdrawing the electrode after use it sometimes 
catches at the cardiac end of the stomach, but if the patient swal- 
lows a little water it slips past. When this electrode is in the 
stomach, which has been previously partially filled with a pint or 
more of warm water or saline solution, the second electrode, broad 
and flat, is placed over the epigastrium or over the back to the 
left of the seventh dorsal vertebra, and the electric current is care- 
fully turned on. 

This treatment is designed especially to increase the muscular 
tone of the stomach in atonic dilatation and stimulate peristalsis, 
but it also serves to promote secretion, and hence it doubly aids 
digestion. The electric current may be applied daily, immediately 
after lavage, for ten or fifteen minutes, and it should be strong 
enough to induce good peristalsis. Even patients who are not 
accustomed to lavage seldom object to swallowing the electrode. 

A variety of medicinal remedies are also used with the object of 
preventing fermentation of food in the stomach and intestine and 
for artificially aiding digestion by these organs. Among the former 
are to be mentioned creosote and other substances allied to carbolic 
acid, naphthaline, salicylic acid, etc. The use of hydrochloric acid 



THE ALIMENTARY CANAL 543 

and pepsin have been described in connection with chronic gastric 
catarrh (p. 531). 



Vomiting— Seasickness— Vomiting of Pregnancy 

Vomiting occurs as a symptom of so many diseases and func- 
tional derangements that it will be advantageous to consider col- 
lectively the general dietetic means for its relief. The details of 
treatment will be explained under the headings of the various dis- 
eases in which vomiting may become a serious or prominent 
symptom. 

Pathological Physiology. — Vomiting as far as it is related to 
dietetics may be caused by: 1. Excess of food. 2. Foods and 
drinks improperly combined (as crabs and milk, beer and cham- 
pagne, etc.). 3. Fermenting or poisonous food. 4. Irritating and 
indigestible food, including that which is improperly cooked. 5. 
Hastily eaten food. 

In hysterical patients and in very neurotic conditions of the 
system, either the sight, taste, smell, or mental suggestion of food 
may excite nausea and vomiting. 

Instances of the influence of the mind over stomach digestion 
and the mechanism of vomiting are too familiar to need elaboration 
here. Food which is in itself nourishing may promptly nauseate 
through disgusting association or environment. For example, a 
party of early California settlers while crossing the continent were 
lost during a severe winter in the Sierras. When nearly dead of 
starvation some friendly Indians took compassion and fed them 
upon a delicious finely ground meal, which for some days was their 
staple article of diet, and on which they rapidly gained strength. 
Being at first unable to understand the Indians, the emigrants could 
not learn of what the meal was composed. When at length they 
found out that it was made from pounded dried grasshoppers it pro- 
duced such nausea that none could touch the food again. 

Dietetic Treatment. — The first principle in the dietetic treat- 
ment of vomiting from any cause is to give the stomach rest. If it 
has been overloaded with a large bulk of food, or with indigestible 
material, it is well to encourage emesis, and distressing retching may 
be overcome by taking large draughts of lukewarm water. A 
quart or two will rinse out the stomach and allay irritation to a 
marked degree. 

Well-nourished patients when serious vomiting first occurs 
should usually refrain from taking food of any kind for from ten 
or twelve to even twenty-four hours. Exceptions to this rule are 
sometimes found in that type of seasickness, and sometimes in the 
vomiting of pregnancy, in which, as soon almost as the stomach 
is emptied, there is a desire to replenish the loss. 



544 DIET IN DISEASE 

In any case in which the gastric irritation is persistent it is 
necessary to give fluid food, and only in small oft-repeated doses, 
preferably in predigested form. The food is best given cold, as a 
rule, although some persons can relieve nausea by sipping very 
hot water. 

A teaspoonful of prepared milk, or in extreme cases but a few 
drops, given with a medicine dropper once in ten or fifteen minutes, 
may be all that the stomach will at first tolerate. 

The following is a list of dietetic substances which are commonly 
prescribed for the relief of nausea and vomiting, or for nourishment 
while those conditions exist : Cracked ice ; pancreatinised milk ; milk 
with sodium bicarbonate (ten grains), and cerium oxalate (five 
grains) ; milk and lime water ; milk and Vichy, soda, Seltzer, or 
carbonic-acid water ; whey ; koumiss and zoolak ; beef extracts 
and peptonoids, such as Johnson's Fluid Beef and Carnrick's Beef 
Peptonoids, somatose, Valentine's or Liebig's meat juice ; raw meat 
pulp, scraped ; strong black coffee ; sour lemonade or lemonade and 
Vichy; clam broth. Dry crackers, dry toast, and ginger-snaps will 
sometimes be retained in seasickness, or a cracker buttered and 
sprinkled with a little Cayenne pepper ; brandy and soda ; iced dry 
champagne ; iced brandy diluted with water, soda water, or Apol- 
linaris. 

Very severe and protracted cases may require lavage or nutrient 
enemata. Vomiting after abdominal surgical operations is often 
controlled by lavage. 

SEASICKNESS 

There is no known dietetic treatment of seasickness which is ap- 
plicable to many cases. There are those who overeat because of the 
tonic of the bracing sea air. The idleness and lack of accustomed 
exercise, and perhaps something in the quality of the air itself, all 
contribute to make them bilious, and unloading stomach and bowels 
thoroughly once for all suffices to cure them for the rest of the 
voyage. The habit of indulging in late " farewell suppers " is nat- 
urally the worst preparation possible for a sea voyage. 

Some persons at sea can leave the table, vomit the first two or 
three courses of a dinner, return, and finish the meal with astonish- 
ing equanimity. With them nausea is not a persistent or annoying 
symptom, and they need no treatment. Others are always nauseated, 
but fail to vomit, and consequently grow weak from lack of food. 
They do well to take a mild emetic at first, and usually a tumblerful 
of lukewarm water will serve to empty the stomach of food lying 
there undigested and fermenting. They are then temporarily re- 
lieved, and can assimilate some form of predigested food. 

Still others, after severe experience with emesis, strongly crave 
and can actually retain and digest, in defiance of all dietetic laws, 



THE ALIMENTARY CANAL 545 

substances which they could scarcely eat at home. Old cheese, nuts 
and raisins, sour pickles, canned lobster, and similar incongruities of 
diet are indulged in without a qualm. 

There is a class of persons of both sexes, though the greater 
number are women, who become so ill at sea as to reach a serious 
condition of prostration. These patients are constantly nauseated, 
not alone by the taste, but by even the sight and odour of food. 
The mere idea of it, as the suggestion from reading an elaborate 
menu, will nauseate. It is often difficult for such patients on a 
crowded steamer to obtain the proper food and service, and it is well 
for them to go provided with certain articles which are most useful. 
Chief among these is sterilised milk. This is now easily obtainable 
before sailing, and there is no difficulty in keeping it fresh during 
the length of an ordinary transatlantic voyage. It may be peptonised 
at the time it is needed, or diluted with equal parts of Vichy or lime 
water, or taken with ten grains of bicarbonate of soda and three 
grains of cerium oxalate to the tumblerful. The Swiss milk, con- 
densed without sugar, may also be used. Fresh lemons and sour 
oranges are very acceptable to many patients, the former particu- 
larly so on account of their greater acidity and special power to quiet 
the nausea of seasickness. The juice of one or two lemons, squeezed 
into a tumbler of iced Vichy or Apollinaris, with a little sugar or sac- 
charin, and a pinch of bicarbonate of sodium, makes a most refresh- 
ing and soothing beverage. 

Prepared clam broth, like milk, can also be taken in bottles, and 
it often allays nausea. It is mildly stimulating and nourishing. 

Other drinks which are recommended besides those above men- 
tioned are weak brandy and soda or Seltzer, cold champagne, or 
sparkling Moselle. Too much ice water should not be drunk, but 
cracked ice may be sucked. Strong black coffee is excellent. If 
there is uncertainty about this being obtained good at sea, the ex- 
tract of coffee may be carried, which can be drunk diluted in hot 
water. Coffee distinctly allays nausea, besides being a good cardiac 
stimulant and diuretic. Some persons can take porter or stout in 
small doses with benefit. 

It is not well to take too much soup or broth at once, for if there 
is much motion the weight of the fluid, tipping about in the stomach 
as the vessel rolls and pitches, may easily accentuate the nausea. 
In some cases patients may retain dry, solid food better than liquids, 
and they should try soda crackers, zwieback, lemon ginger-snaps, 
and chipped smoked beef, which can be obtained in boxes at the 
grocer's before sailing. In extreme cases it may be necessary to 
use beef peptonoids or other meat preparations, such as beef meal, 
given either by mouth or in enemata. The white of egg may be 
given in brandy. Preserved dry ginger helps some persons. Lime- 
water tablets may be used. 



54 6 DIET IN DISEASE 

Epigastric applications of hot-water bags or mustard pastes afford 
relief. It is desirable to lie down at once after taking food, and lie 
perfectly horizontal, without a pillow. It is very important to keep 
the bowels freely open with bitter water of some sort. Rubinat is 
less objectionable in taste than others. Seidlitz powders are usually 
well retained, and so is citrate of magnesia. 

VOMITING OF PREGNANCY 

The vomiting of pregnancy usually takes the form of simple 
" morning sickness." This may not appear until the patient arises 
in the morning, when she feels faint, dizzy, and nauseated. Such 
cases are benefited by remaining in bed until a glass of milk, or a 
cup of warm broth with a biscuit, or a cup of cocoa or coffee and a 
sandwich has been taken and digested. There may then be no re- 
turn of nausea during the day, but the diet should at all times be 
simple, especially the last meal of the day, and all richly cooked 
food, pastry, sweets, sauces, and elaborate " made dishes " should be 
avoided. Beyond this such patients may need no further treatment. 

In other women the nausea is more persistent, and in the worst 
instances the symptom is very difficult to control by any therapeutic 
or dietetic measures. 

Such cases are to be treated on the lines suggested above for the 
cure of vomiting in general and for severe seasickness. Nutrient 
enemata should be early resorted to if there is any sign of failing 
strength, and before a patient is allowed to die of inanition artificial 
delivery may be necessitated. Such extreme cases are fortunately 
very rare. 

The treatment of other forms of vomiting will be considered 
under the headings of Alcoholism (p. 393), Acute Gastritis (p. 
528), Chronic Gastritis (p. 531), and Dilatation of the Stomach 
(P- 537). 

Ulcer of the Stomach 

In ulceration of the mucous membrane of the stomach there is 
danger of irritation of the abraded surface through either the 
chemical or mechanical action of the food. Excessive secretion of 
gastric juice itself is believed to be similarly irritating. In serious 
cases where the ulcer is extensive or where it is deep and the stom- 
ach wall is thinned, there is liability of a rupture being caused by 
overdistention or an undue amount of peristaltic action. In the 
normal relaxed condition of the stomach wall the mucous membrane 
is folded into rugae, but when it is slightly distended the surface is 
smoothed out, and a greater degree of stretching may rupture an 
ulcer which is on the point of perforation, but which might still 
heal over if the tension were not too great. Further danger from 
the presence of ulcer of the stomach lies in the fact that small blood 



THE ALIMENTARY CANAL 547 

vessels may be occasionally eroded, giving rise to profuse haemor- 
rhage, and any food which irritates the surface of the ulcer increases 
this risk. 

Dietetic Treatment. — For these reasons, if the patient is seen 
soon after the occurrence of gastric haemorrhage, it is necessary to 
withhold all alimentation from the mouth and nourish the patient 
exclusively upon nutrient enemata. This treatment permits the 
stomach to remain relaxed, and it is not stimulated to peristalsis or 
secretion of irritating gastric juice. 

In addition to the ordinary nutrient enemata it may be advis- 
able twice a day to give rectal injections of a pint of salt water, 
which by its absorption prevents thirst and relieves the patient of 
the craving for swallowing liquid, which might result in exciting 
further vomiting. In severe cases, if the irritability of the stomach 
continues or the haemorrhage is repeated, it becomes necessary to 
continue the rectal alimentation for many days, and patients may 
live upon it comfortably for a week or, in some cases, much longer. 

Lavage has been employed successfully when vomiting and pain 
in the stomach were uncontrollable. One usually hesitates in 
adopting this practice on account of a fancied danger of pushing 
the oesophageal tube through the weakened wall of the stomach, 
and I have known of one case which resulted fatally from this 
procedure, where the stomach wall, however, was already eroded 
through both the mucous and muscular layers, and perforation in 
any event was imminent. When the. stomach wall is weakened the 
mere act of vomiting itself is a menace of rupture, and the opera- 
tion of lavage is justifiable if carefully performed. There is no 
special danger to be apprehended from the use of a very flexible 
tube which is not pushed too far into the stomach, as the ulcer is 
usually some distance from the cardiac end, and food can sometimes 
be poured into the stomach through the tube after lavage with 
alkaline water, when it may be retained and digested. This treat- 
ment should only be resorted to in cases where haemorrhage has not 
occurred within a week, and in which other efforts to control pain 
and irritation of the stomach have been faithfully tried, but have 
failed. 

Debove recommends the use of the oesophageal tube for gav- 
age when vomiting is persistent and nutrient enemata are not satis- 
factorily retained. The tube should be passed as far as, but not 
necessarily into, the stomach, and fluid food is poured through it. 
The act of swallowing is thus avoided, and emesis, as in the case of 
infantile dyspepsia, is less likely to follow. If the tube proves irritat- 
ing its use must not be insisted upon. 

Generally speaking, however, after a day or two of complete 
rest the condition of the stomach will admit of the gradual resump- 
tion of mouth feeding, but nourishment must be given exclusively 



548 DIET IN DISEASE 

in liquid and predigested form. The object is to give only food 
which will tax the stomach as little as possible, and either be 
promptly absorbed or pass quickly into the duodenum. 

At first but very small quantities, not exceeding one or two tea- 
spoonfuls, should be offered at one time, and the effect in regard to 
nausea or vomiting must be carefully observed. Later, from four 
to six ounces should be given every two hours. For those cases of 
ulcer of the stomach in which patients are allowed to take food per 
os, a milk diet will usually agree the best, provided precautions are 
observed against the formation of large curds in the stomach, which 
are exceedingly irritating. The milk should be given in any form 
in which it is best borne, and the reader is referred to the article 
upon the modes of preparing milk and rendering it digestible (p. 
75). If it is tolerated, the dosage may be increased to three to 
four ounces every two hours. Peptonised milk gruel is strongly 
recommended by Roberts. Da Costa has found that ice cream gave 
unexpected relief in some cases. Some patients do well upon 
koumiss, buttermilk, or zoolak. Ewald advocates the use of milk 
thickened with flour of various kinds to prevent the formation of 
large coagulae. The predigested starchy infant foods, such as Nes- 
tle's, Mellin's, Imperial Granum, or malted milk, may be added, but 
gruels made with coarse cereals are not permissible. 

When milk preparations fail, it is unwise to persist in giving 
them, and teaspoonful doses of beef juice should be substituted, or 
peptonised solutions or pancreatinised meat juice may be tried. 
Other patients may be fed upon tgg albumin beaten and sweetened 
or prepared with sherry wine, or the yolk of an egg may be beaten 
in an ounce of boiling water and added to a tumbler of milk. Less 
serious cases may be allowed such articles as zwieback or stale 
bread crumbs or cracker crumbs soaked in milk until quite soft. 
They will prevent the formation of large coagulse of milk. One of 
the various malt preparations may be well tolerated and prove 
nutritious. Leube's Soluble Meat is a German preparation, which 
relieves the stomach of all necessary work, and consequently re- 
duces the period of acid secretion in the stomach. It proves very 
serviceable in the dietetic treatment of gastric ulcer, and may be 
given alone or combined with milk or salted meat broths and bread 
crumbs. Leube himself prescribes in this form an equivalent of 
half a pound of beef in twenty-four hours, and claims good success 
for it. Mosquera's meat jelly may be employed. 

As a rule, if a patient thrives upon a diet of milk and broths, 
it is best to let well enough alone for three or four weeks, and any 
increase in either the quantity or variety of the diet should be made 
with extreme caution. If improvement follows, as indicated by the 
diminution in pain and the absence of gastric distress after eating, 
and the patient gains in strength, other articles may be carefully 



- THE ALIMENTARY CANAL 549 

added in moderation to the diet, such as milk toast, sweetbread, 
eggs (not hard-boiled), scraped meat, custard, a small piece of 
boiled or broiled white meat of chicken or mutton or fish, chicken 
broths thickened with arrowroot, rice, vermicelli, clear meat broths 
or thickened soups to which the yolk of an egg has been added, 
or crumbled dry toast and a carefully prepared puree of potatoes may 
be prescribed. Stewart recommends the addition of malt to the 
puree. 

A few easily digestible solid foods may next be added to the 
menu, such as tender rare roast beef, beefsteak, tender game, like 
the breast of partridge, quail, or squab in season. The soft part of 
large oysters (raw or broiled), boiled fresh fish, such as bass, sole, or 
whiting, rice pudding, bread and milk pudding, tapioca, sago, farina, 
and cornstarch — are all articles which may be permitted in modera- 
tion. 

The patient should be informed of the existing condition in the 
stomach, and of the dangers attending any serious departure from 
the rules of diet carefully laid down, and it should be explained 
that for several months after the acute symptoms of gastric ulcer 
have subsided the greatest care must be observed not to overload 
or overwork the stomach, and to refrain from eating food such as 
coarse bread or groats, or vegetables having tough outside cover- 
ing, like peas, corn, and beans, all of which are liable to produce 
mechanical irritation. No fruit except orange, lemon, or peach juice 
should be allowed. 

Osier recommends the following menu for gastric ulcer : 

8 a. m. — Two hundred cubic centimetres of Leube's beef solution. 

12 m. — Three hundred cubic centimetres of milk gruel or pepto- 
nised milk gruel made with ordinary flour or arrowroot, to which 
gruel an equal quantity of peptonised milk is added. 

4 p. m. — Buttermilk. 

8 p. m. — Gruel. 

In addition, rectal alimentation is to be given. The whites of 
eight eggs may be used in alternation with the beef solution. 

After a month of this treatment the following articles are cau- 
tiously given : Scraped beef, chicken, fresh sweetbread, a farina- 
ceous pudding made with milk and eggs. This treatment should 
last three months, most of which time is to be spent in bed. 

The rules for stimulants are that they should be absolutely for- 
bidden unless they become necessary through exhausting haemor- 
rhage or great weakness, in which event they had better be supplied 
through the rectum. 

Von Ziemssen prescribes Carlsbad water in order to neutralise 
the acidity of the stomach and hurry its contents into the duodenum. 
He recommends drinking half a pint to a pint of this water hot early 
in the mornings during convalescence. 



550 DIET IN DISEASE 

Aerated waters should not be recommended. The gas is apt to 
distend the stomach, and the carbonic acid is believed to be irritating 
to the raw surface of the ulcer. 



Cancer of the Stomach 

In cancer of the stomach, prolongation of the patient's life and 
personal comfort depends more upon the dietetic than any other 
form of treatment. Nourishment should be given in a concentrated 
and predigested form, and where pyloric obstruction exists, in a 
condition which admits of direct absorption from the stomach wall. 
It is necessary to avoid food that is liable to remain long in the 
stomach and excite nausea and vomiting, which may in turn develop 
severe pain or fatal haemorrhage, and to prohibit anything which 
by undue fermentation might cause distention and stretch an already 
thinned gastric wall to the point of perforation. 

Osier mentions that in organic disease of the stomach pain usu- 
ally begins soon after eating and continues until its digestion is over 
or vomiting occurs, but sometimes the pain of carcinoma may be re- 
lieved by ingestion of food. 

Aside from the local difficulties of digestion in gastric carcinoma 
in the immediate vicinity of the stomach wall, the gastric juice is 
either deficient in amount or altered in composition, and the hydro- 
chloric acid may be totally absent. Hence stomach digestion can- 
not be counted upon at all, and it is important to digest all food by 
artificial processes. 

In nearly all cases nutrient enemata will sooner or later be re- 
quired either as an adjunct to stomach feeding or to replace it en- 
tirely. Owing to the importance of this subject, it will be separately 
discussed. (See p. 408.) 

If much pain follows the ingestion of any food, or if there is a 
tendency to haemorrhage, stomach feeding should be entirely re- 
placed in this manner. In no other disease can life be supported for 
so long a time and so comfortably upon exclusive rectal alimentation. 
After a few days of rest secured by substitution of enemata the 
stomach may become less intolerant and food can again be swal- 
lowed. 

The exact nature and site of a carcinomatous lesion cannot 
always be determined, especially in its early stages, and each case 
requires special study. Patients soon find by experience what gives 
them most distress and learn to avoid it. In general, saccharine and 
farinaceous foods should be proscribed because they are normally 
not digested in the stomach, and in carcinoma they linger and, aided 
by the catarrh which is usually also present, undergo abnormal fer- 
mentation with production of gas, nausea, and vomiting. It is usu- 
ally the case that predigested albuminous food is better assimilated. 



THE ALIMENTARY CANAL 551 

Digestion in such cases should be watched from day to day, and when 
patients can tolerate a little simple farinaceous food without its pro- 
ducing eructations or increasing the gastric pain and discomfort, it 
may be added. 

If the new growth causes stricture of the cardiac end of the stom- 
ach, only fluid food can be taken, and the act of swallowing should 
be studied to make sure that dilatation of the oesophagus is not devel- 
oping. If, on the other hand, it constricts the pyloric end, food can- 
not pass on into the intestine and gastric dilatation may result. It 
then becomes highly important to put into the stomach only that 
which can be absorbed from its wall. Such substances, besides 
water, include peptones, albumoses, and alcoholic stimulants (cham- 
pagne, whisky, and brandy), all which may be taken up by the cir- 
culation of the gastric wall in considerable quantity. Albumoses 
would theoretically constitute a most useful food, being entirely pre- 
digested and ready for immediate absorption ; but practically patients 
soon weary of such a diet, and food of that nature will not long sup- 
port life when given alone. In complete pyloric obstruction albu- 
moses may be prescribed, and in advanced gastric dilatation they are 
needed. They may be sometimes alternated with other foods with 
advantage. 

If much dilatation exists without nausea or vomiting, fluid foods 
will sometimes lie unabsorbed in the stomach for one or two days, 
and then several quarts of fluid will be unexpectedly ejected. It is 
consequently advisable to examine and percuss the stomach from 
time to time, to make sure that nourishment swallowed is not accu- 
mulating there. 

Exceptionally, if the disease has not progressed too far, patients 
do best on a dry diet, and finally chopped steak, tender rare beef, 
chicken, scraped beef, soft-cooked or raw eggs may be given, and 
digestion is facilitated by the use of pepsin and hydrochloric acid or 
papoid. If there is no pyloric obstruction, and if it does not produce 
nausea or pain, simple forms of starchy food may be added, such as 
dry bread, toast, or crackers. 

In advanced cases the diet must be fluid and concentrated ; food 
should be given only in very small quantities — not over one or two 
teaspoonfuls at one time, frequently repeated. Meat extracts, albu- 
moses, buttermilk, pancreatinised milk, koumiss, and prepared 
egg albumin may be retained. The yolks of eggs are not ab- 
sorbed from the stomach on account of the fat which they contain. 
When possible, the diet should consist almost wholly of predi- 
gested milk. 

Oppolzer advises the use of sour milk in cases of carcinoma of 
the stomach in which there is more or less constant tendency to vom- 
iting, and in which ordinary milk coagulates in the stomach in large 
curds. Sour milk is much less apt to form large tough coagulae. It 
37 



552 DIET IN DISEASE 

is usually better, however, in such cases to pancreatinise the milk or 
give it in the form of koumiss. 

For the control of vomiting there may be also tried iced carbon- 
ated water, champagne, bismuth, and counter-irritation. For indi- 
gestion, eructations, or gaseous distention, antacids and antifer- 
mentatives are indicated, or pepsin with dilute hydrochloric acid. 

Ewald says : " A diet of starches and vegetables is more easily 
borne than that of meat, since the diminution in the secretion of 
hydrochloric acid causes the digestion of albumin and meat to be 
incomplete. In most cases milk is also poorly borne, on account of 
the absence of rennet." When milk is tolerated, however, he advises 
the addition of a few drops of Cognac to each tablespoonful, or the 
use of kefir or peptonised milk. 

Many special systems of diet have been exploited for the treat- 
ment of cancer of the stomach, some of which have proved of 
occasional value, and have at least the merit of being based upon 
scientific reasoning, whereas others are pure quackery. It is almost 
needless to say that no such thing as a dietetic " cure " for cancer ex- 
ists. The most that can be expected of any dietetic system for this 
fatal disease is that it may make the patient somewhat more com- 
fortable, and prolong his life perhaps for a few weeks or months by 
maintaining better general nutrition. 

Lavage is sometimes employed as an adjunct to dietetic treat- 
ment where much catarrh of the stomach or dilatation is present. It 
may relieve some of the symptoms in the early stages of the disease, 
but it should be performed with great care, for it is uncertain to what 
extent the stomach wall may be eroded. I have known of at least 
one case in which a fatal result followed the false passage of an 
oesophageal tube. 

DlARRHCEA 

Pathological Physiology. — Diarrhoea is commonly the result of 
excessive peristalsis. It may also be occasioned by the presence of 
a large volume of fluid in the intestine, caused either by lack of 
absorption of an excess of liquid ingested, or oftener by hypersecre- 
tion or failure to absorb the fluid of the chyme. 

The exaggerated peristalsis is occasioned — 

1. By increased irritation of the nerves or muscles of the intes- 
tine, due to mechanical stimulation of irritant or undigested particles 
of food (e. g., the seeds of berries or husk of corn grains). 

2. By chemical products which are contained in the food. 

3. By abnormal fermentation, the products of which excite mus- 
cular contractions. There are many dietetic causes of diarrhoea. It 
may be produced by fermented or putrefactive food, by improper 
food mixtures, by food which is too coarse, bulky, and irritating, or 
by monotony of diet. The excessive use of meat extracts or " pep- 



THE ALIMENTARY CANAL 553 

tones " is liable to cause it. In the tropics, as shown among the 
troops employed in Cuba and Porto Rico in the Spanish-American 
war, it may originate from a salt-pork ration, the consumption of too 
much meat, canned dried beans (" baked beans "). In the tropics 
and in hot weather, generally, catarrhal enteritis is easily excited, and 
animal food soon spoils if exposed to the heat and air. 

Diarrhoea may be (a) acute, due to temporary errors in diet, " tak- 
ing cold/' causing acute intestinal catarrh, the ingestion of poisons, 
overdoses of aperients, etc., or (b) chronic, complicating some intes- 
tinal or other malady. 

Acute diarrhoea often subsides of itself if food be withheld until 
the irritant matter has passed off from the intestine. 

Chronic diarrhoea of long standing requires great care and pa- 
tience in treatment. 

Abundant greenish fluid stools showing much bile pigment indi- 
cate that the stools have been hurried out of the small intestine 
before digestion was complete. 

Of the many forms of diarrhoeal diseases, the treatment of those 
only which are most influenced by diet will be discussed in the suc- 
ceeding pages. There are a few propositions which have general 
application to the different varieties, which will be mentioned here. 

Dietetic Treatment. — It is a general rule to moderate the quantity 
of food and avoid all food likely to undergo abnormal fermentation 
(such as sugars), or having a considerable residue. Unirritating or 
bland substances only should be taken. Fruits and vegetables must 
be wholly interdicted. 

At the commencement of an acute attack food may be withheld 
for ten or twelve hours, and a little barley water or arrowroot gruel 
flavoured with a mere taste of lemon or spice should then be or- 
dered with one or two tablespoonfuls of brandy in soda water. Mut- 
ton or chicken broth may next be given, and, if desirable, it may be 
thickened with boiled rice, tapioca, sago, or cracker crumbs. Pa- 
tients who are not at the same time " bilious " or vomiting may 
take milk diluted with one third lime water. 

The return to ordinary diet should be in all cases gradual, and 
such articles as milk toast, oysters, well-cooked macaroni, boiled 
rice with beefsteak gravy, the breast of boiled chicken, or a little, 
partridge in season, with baked and mashed potatoes, may be first 
allowed. 

Loose stools sometimes occur immediately after meals, the im- 
pulse for the bowels to move coming so suddenly that the patient 
scarcely has time to leave the table for the closet. In such cases 
" some one article of diet is at fault " (Osier). The patient should 
be put upon a diet restricted mainly to meat and stale bread or toast 
for a few days, and made to lie down and rest immediately after 
meals. Taking food into the stomach excites a reflex intestinal 



554 DIET IN disease 

peristalsis, and the intestinal contents are hurried onward before they 
can be digested. 

For the form of diarrhoea which occurs in hysterical women, if a 
milk diet is not well borne, Osier recommends feeding the patient 
upon egg albumin exclusively while medicinal antispasmodics are 
given to diminish peristalsis. 

In diarrhoeas demulcent and mucilaginous drinks are useful, and 
they are believed to coat the alimentary canal and protect it from 
local irritation. It is doubtful, however, whether any such action 
occurs beyond the stomach. 



DlARRHCEA IN INFANTS AND YOUNG CHILDREN 

Dietetic Causes. — The dietetic causes of diarrhoea in infants and 
young children may be classed as due to — 
i. Too frequent or irregular feeding. 

2. Overfeeding. 

3. Feeding with improper or " spoiled " food. 

The first and second causes are commonest in early infancy, and 
the third is commonest in childhood, although any or all of them 
may operate at any age. 

Children brought up in the country are much less subject to diar- 
rhoeal disorders than those raised in cities, owing to the relative 
purity of their milk and other foods, and the greater resisting 
power with which their better general health and vigour supplies 
them. 

In a series of nearly two thousand cases among infants of fatal 
diarrhoea, collected by various observers (Hope, Meinert, Ballard), 
only 3 per cent received the breast exclusively. These are very sig- 
nificant data, and point to the conclusion that the vast majority of 
cases are due solely to the use of improper or contaminated food. 

Differences in the mere chemical composition of the cow's milk 
used for feeding are not sufficient to account for the frequency of 
diarrhoeal diseases, and the further conclusion is reached, and has 
been sustained by bacteriological research, that the harm is caused 
by noxious germs. 

Diarrhoea occurring in nursing infants must be accounted for in 
other ways, although germs may readily have access to the child's 
mouth from an unclean nipple or from sucking its own soiled fingers. 

Aside from this, anything which disturbs the mother's digestion 
may excite diarrhoea in her baby, as, for example, improper food, 
menstruation or pregnancy (rarely), strong nervous influences, such 
as grief or worry, great exhaustion, extreme anaemia, the use of cer- 
tain powerful drugs. 

Evidently the intestine becomes stronger or less susceptible to 
bacterial poisons after the first two years or thirty months of life, 



THE ALIMENTARY CANAL 555 

for the frequency of serious diarrhoea lessens, although the child 
often gets worse milk to drink than it had when fed upon the bottle. 

It has been suggested that water may excite diarrhoea by hur- 
riedly washing germs into the intestine which are ordinarily killed 
in transit by the acid of the stomach. The bile is reputed to be 
antiseptic, but Booker has found that all bacteria will grow in a 
io-per-cent solution of it, and it easily undergoes fermentation from 
decomposition of its mucus. Its antiseptic reputation rests upon 
the fact that it stimulates peristalsis, keeps the bowels moving, and 
thereby prevents food from accumulating and fermenting abnor- 
mally. 

In large cities, where women among the poor are obliged to go 
out to work by the day, they, as a rule, suckle their infants for only 
the first six months, or if for a longer period, they add other food or 
have their babies bottle-fed by a neighbour or in a " day nursery " 
during the hours in which they themselves are away from home. 
Such hand-fed children are often given more than they can assim- 
ilate. 

As the infant grows older it is brought to the family table, and 
when a year and a half old it is not seldom stuffed with any articles 
from it. Beer, sausages, bananas, potatoes, tea, and coffee — all are 
given. 

Overfeeding and the use of such harmful food maintains almost 
constant dyspepsia, and if it does not itself cause diarrhoea it predis- 
poses to it by keeping the alimentary canal in a constant state of 
irritation or hypersemia, so that slight additional factors excite the 
condition, and bacteria find a fertile soil in which to develop. 

In older children foods which are among the commoner causes 
of diarrhoea are unripe or overripe fruits of all kinds, berries with 
seeds, vegetables having a tough outer envelope, such as old 
peas, beans, and green corn, imperfectly cooked cereals, like coarse 
hominy, rice, or oatmeal, nuts, raisins, and dried currants. Gener- 
ally speaking, diarrhoea is more apt to be caused by fruits and tough 
meats imperfectly masticated than by vegetables. 

Examination of the Stools. — In all serious cases the stools should 
be examined, if possible, microscopically, to determine the degree 
of digestion and absorption of the food. The chief abnormal in- 
gredients are fat, bacteria, mucus, casein, starch, and, if meat has 
been eaten, muscle fibres. The green diarrhoea of infancy is usually 
of microbic origin. Diarrhoea of putrid character is due to albu- 
minous fermentation, and produces more severe symptoms (see pto- 
maine poisoning) than those produced by the simple fetid stools of 
starch fermentation. 

Fat. — The normal percentage of fat which the stools contain is, 
according to Uffelmann's analysis, fourteen on the average, but in 
diarrhoea with intestinal dyspepsia it rises often to forty or fifty, and 



556 DIET IN DISEASE 

it has reached sixty-four. The fat appears in minute white flocculi, 
varying in size from that of a pin's head to a split pea. These small 
masses are often mistaken for casein, but the careful researches of 
Wegscheider, Baginsky, and others have demonstrated them to be 
composed of inspissated fat and colonies of bacteria. It is an easy 
matter to distinguish them from casein, as they alone are dissolved 
by the addition of a few drops of alcohol and ether. 

Bacteria. — The commonest bacteria of infant stools are the 
Bacterium lactis aerogenes and the Bacterium coli commune. In fact, 
these two normal varieties are the only constant kinds in milk- 
fed babies (Escherich), although Booker has found in different 
cases of infantile diarrhoea, and especially cholera infantum, forty 
varieties in all which bear no special relation to particular foods. 
The first-named germ occurs only when milk has been ingested, for 
it thrives, as its name indicates, upon lactose. Its chief site is the 
small intestine, where it causes milk to ferment. The Bacterium 
coli commune, on the contrary, elects the large intestine and thrives 
upon the residue of digested food. Booker is of the opinion that 
the influence of the various pathogenic germs in the production of 
diarrhoea is attributable more to alteration of the food and intestinal 
contents than to direct irritation of the intestinal wall. 

Casein. — Undigested casein is a less common ingredient of the 
stools than was supposed before the above-described observations 
were made. When present it is in the form of smooth, somewhat 
hard masses, often of a yellow or yellowish-white colour without, 
but white when broken open. They are usually friable, and have a 
cheesy odour. They may present a semi-transparent or horny ap- 
pearance. 

Starch. — Starch granules appear in the stools very often when 
imperfectly cooked amylaceous food has been eaten, such as oat- 
meal, barley, potatoes, bread, etc. 

They are recognised by the microscope, and by the addition of a 
solution of iodine, which colours the stools dark blue. 

Meat Fibre. — Muscle fibres are easily recognisable by micro- 
scopic examination, but not otherwise. 

Dietetic Treatment. — The principles of dietetic treatment of 
simple bacterial or mycotic diarrhoea occurring in infants under two 
years of age are, first, to give the alimentary canal rest, and, sec- 
ondly, to give food which is very thoroughly absorbed, leaving the 
least possible residue of waste. All food is to be withheld for a few 
hours, and cool sterilised water or barley water, and cracked ice 
(if pure) is given to allay thirst. The child will not suffer from lack 
of food. It will suffer much more with it. If stimulants are needed, 
ten to thirty drops of brandy, well diluted, may be prescribed. 

After the interval of rest food is to be cautiously administered, 
but in less than the usual quantity. Unless the infant can have 






THE ALIMENTARY CANAL 557 

breast milk, which is usually most desirable for it, it is best to give 
no milk at all, but instead such articles as whey, thin mutton or 
chicken broth, barley gruel, or tgg albumin beaten in half a pint of 
cold water to which a teaspoonful of brandy and a pinch of salt are 
added. After two or three days of this diet, if the child continues 
to improve, the milk diet given before the illness is to be gradually 
resumed, but the feeding should be watched with care for at least 
a week. 

To older children, when diarrhoea has been excited by eating im- 
proper food, unless the bowels have been already very thoroughly 
evacuated, or if signs of intestinal irritation continue, it is best, as 
with adults, to give castor oil and opium in the form of paregoric or 
Dover's powder, and then to feed the child upon the principles laid 
down above for infants. As a rule, it is best to avoid " prepared 
foods " or patented infant foods, and good nutritious home-made 
fresh broth from well-selected lean mutton, or chicken or beef broth, 
is decidedly to be preferred. 

Enterocolitis in Infants and Children — Summer 

Diarrhoea 

Summer diarrhoea is exceedingly fatal among infants in hot 
weather in densely populated localities, and they require very care- 
ful feeding for this disease. Intractable cases are prolonged for 
several weeks, with more or less vomiting, diarrhoeal mucous stools, 
fever, and meteorism, and a variety of complications supervene ; 
hence there is ample opportunity for the exercise of dietetic skill. 

Prevention. — Entero-colitis is a subacute milk infection resem- 
bling the acute form, cholera infantum, but it is less violent, although 
much more prevalent. It is produced by toxins developed by the 
activity of bacteria in the food, and it is therefore to a large extent 
preventable, and most easily so by continued and exclusive breast 
nursing. 

The preventive treatment for weanlings in nurseries where there 
are several children consists in absolute cleanliness and antisepsis, 
and the nurse must be made to realise the necessity of disinfecting 
diapers and her own hands at once, and she must never handle either 
food or food utensils with soiled hands, for by neglect of these sim- 
ple precautions the germs are passed on from one child to another. 
When cow's milk is used in hot weather it must always be sterilised 
or Pasteurised. 

Dietetic Treatment. — If the child is still nursing, and the moth- 
er's milk is found to disagree, a wet nurse should be secured when- 
ever possible ; or if it is bottle fed, great care should be taken 
to introduce only sterile food into the stomach. If the child is 
fairly strong and well nourished at the commencement, it is best 



558 DIET IN DISEASE 

to withhold all food for several hours, and merely give a little barley 
water or some equally bland beverage. In any event it is best to 
abandon milk and its preparations entirely for two or three days. 
In this manner the intestinal germs which are causing the mischief 
are starved out or replaced by others which are comparatively in- 
nocuous. 

There are many cases of enteritis in children in which milk 
wholly disagrees, even when Pasteurised or pancreatinised, appar- 
ently because the casein is not properly digested in the stomach, and 
in such cases the casein should be prevented from passing through 
the alimentary canal in tough and irritating coagulse. 

Fresh meat broths (beef, mutton, or veal), pressed-meat juice, and 
egg-albumin solution with ten to thirty drops of diluted whisky or 
good brandy, are to be given in lieu of all milk. Children a year or 
more old may have gruels of arrowroot, barley, or rice, but commer- 
cial baby foods and patented meat extracts must be omitted. A 
mixture of cream and water is sometimes well borne. 

It is important to give nourishment in very moderate quantity, 
one or two teaspoonfuls at a time, to prevent overfilling of the 
stomach. For older children a little scraped beef may be prescribed 
three times a day ; and they may be allowed to drink whey. 

After several days, but not until the symptoms have well-nigh dis- 
appeared, a very gradual return to Pasteurised milk is permissible. 

In those cases in which children lose all appetite or infants per- 
sistently refuse to take the bottle, the prognosis is extremely un- 
favourable, and recourse must be had to rectal feeding and stimu- 
lation. 

In every protracted case an exact record must be kept of the 
quantity of food taken, and no general report should be accepted 
from the nurse that the child is simply " feeding well." Frequent 
weighing and comparison with the amount of food ingested, com- 
bined with personal observation of the stools, are the best guides for 
the physician to follow in regulating the diet, and they should never 
be neglected. 

During convalescence older children must be carefully watched 
to see that they do not surreptitiously, or through ignorance of their 
nurses, obtain unwholesome food. Such articles as potatoes, toma- 
toes, and other fresh vegetables, coarse cereals, like oatmeal, wheaten 
grits, and corn meal, must be forbidden, as well as fruits. Holt has 
seen a fatal issue from eating a few raisins. 

Cholera Infantum, or Acute Milk Infection 

Cholera infantum is a gastro-intestinal disease of violent acute- 
ness, characterised by severe vomiting, purging by serous stools, 
collapse, very rapid emaciation, thirst, fever, and other symptoms. 



THE ALIMENTARY CANAL 559 

According to Holt, between 2 and 3 per cent of the cases of diarrhoeal 
disease in infants are cholera infantum. 

It does not occur in nursing infants, but only in those fed by 
artificial means. No specific micro-organism has been detected, 
although various germs abound in the watery evacuations. 
Vaughan believes it to be due to tyrotoxicon, which he has demon- 
strated in cow's milk, and which exists only in milk or some modi- 
fied form of it, such as condensed milk, or baby food made in part 
of milk. 

The disease prevails especially in hot weather, and is so rapidly 
fatal, usually within one or two days, that very prompt and vigorous 
treatment is imperative. 

Dietetic Treatment. — The giving of milk in any form must be im- 
mediately and peremptorily stopped, and, as Vaughan says : " Pre- 
pared baby foods should be thrown out of the window. Acute milk 
infection is a form of poisoning by a substance more powerful and 
deadly than white arsenic." The poison must therefore be washed 
out ; and no matter how much vomiting and diarrhoea have already 
occurred, the stomach must be cleansed by lavage, and the colon 
must be irrigated by at least a gallon of warm Castile soapsuds and 
water, after which cool water with fifteen to thirty grains of tannic 
acid to the pint should be injected (Vaughan), with the object of 
precipitating poisonous proteids. The irrigation has a further ad- 
vantage in that it replenishes by absorption a portion of the water 
which has been rapidly drained from the system by the violent purg- 
ing, as in the case of Asiatic cholera, and the loss of which causes 
insatiable thirst. The lavage allays gastric irritability, and alcoholic 
stimulation must then be ordered in the form either of half a tea- 
spoonful of iced champagne or from ten to fifteen drops to a tea- 
spoonful or more of whisky or good brandy, diluted in water or 
Vichy. 

From four to six or eight ounces may be given in twenty- 
four hours to avert collapse. If necessary, the brandy is to be 
given by rectum, or the whisky, in extreme cases, by hypodermic 
injection. 

Accessory means are bathing in warm mustard water and friction. 
No nourishment except the alcohol is allowable for at least twenty- 
four hours, when warm meat juice, koumiss, zoolak, pancreatinised 
meat broths, or egg albumin with whisky is to be prescribed in tea- 
spoonful doses every half hour or hour. For a day or two this diet 
will suffice, and milk should not be again given until the expiration 
of that time, when the ordinary previous diet may be cautiously re- 
sumed. 

Older children may be allowed to have junket and scraped beef 
which has been squeezed through a sieve. 



560 DIET IN DISEASE 



Cholera Morbus— Acute Catarrhal Enteritis in 

Adults 

Cholera morbus may be caused by the ingestion of indigestible 
foods or improper drink, such as polluted water, or water or beer 
drunk in large quantity after long-continued thirst, or chilling after 
excessive exercise and perspiration. An attack may be excited by 
unripe fruit and vegetables, such as green apples, watermelons, cu- 
cumbers, or nuts. 

Dietetic Treatment. — The patient must be kept quiet in bed, 
well covered, and in severe cases it may be advisable to give no food 
for the first twenty-four hours, after which the diet should be very 
light, consisting of meat broth or of pancreatinised milk with lime 
water in the proportion of one third of the latter, given alone or with 
a little boiled rice or milk toast. Brandy and soda or champagne 
may be prescribed. The desire to drink water constantly should be 
restrained, as it tends to keep the contents of the intestine too fluid 
and increases the diarrhoea. Thirst may be relieved by cracked ice, 
very weak cold tea without sugar, or oatmeal water. When the pa- 
tient is first seen, if there is evidence of accumulation of irritating 
food in the intestine which has not been wholly eliminated by the 
diarrhoea, it is advisable to evacuate the bowel with a dose of castor 
oil or salts. 

The following day, if diarrhoea and vomiting have ceased, the 
diet may be increased slowly ; otherwise it must be still restricted to 
broths and milk. Among the foods which may be first allowed are 
a soft-cooked ^gg, raw oysters, scraped beef with soda crackers or 
toast, and well-boiled rice. If the attack has lasted but a day or 
two, the patient may soon return to his normal diet; but if it has 
been protracted, or if he has been much weakened by it, he must 
observe caution in eating for several days. The diet for convales- 
cence given on p. 435 may then be followed. 

Intestinal Putrefaction 

This condition is very common and has a great variety of causes. 
It may be due to the eating of putrefactive food, to indigestion, 
either gastric or intestinal, to nervous exhaustion, as in neuras- 
thenia, etc. It is especially common in epilepsy, chronic Bright's dis- 
ease, acute melancholia, and hepatic disorders. In children it may 
be caused by oatmeal and other carbohydrates. It gives rise to 
flatulence, colic, offensive dark-coloured stools, often diarrhoeal, and 
to a foul breath. Indicanuria is common. In bad cases it causes 
auto-intoxication with a variety of nervous and other symptoms. 
The bowel should be cleansed by a calomel purge or castor oil, and 



THE ALIMENTARY CANAL 56 1 

intestinal antifermentatives, such as creosote or guaiacol carbonate, 
bismuth subgallate, salol, or beta-naphthol, should be given. The 
diet should temporarily consist of broths and gruels. After two or 
three days such foods may be given to adults as rare beef, chicken, 
boiled rice, dry toast, shredded wheat, and crackers. For some time 
such foods should especially be avoided as butter and other fats, the 
nitrogenous vegetables, and sweets of all sorts. 

Chronic Enteritis in Adults — Chronic Intestinal 
Catarrh — Chronic Colitis 

In severe cases it is often advisable to put the patient upon a 
milk diet for several weeks. Except in tuberculous subjects this is 
often successful in effecting a cure. The milk may be skimmed or 
boiled and diluted with lime water. As a rule, fatty and saccharine 
food is forbidden, and farinaceous food should be restricted in 
quantity. At first fats fail of digestion in the intestine, and later 
other foods. Patients must be especially instructed to take their 
meals very slowly and masticate sufficiently. The diet should con- 
sist chiefly of bread and lean meats — foods which leave the least 
residue. Scraped beef, beef meal, and beef peptonoids are useful. 
The intestinal indigestion may be improved by the use of pancreatic 
extracts with bicarbonate of sodium. The food may be pancrea- 
tinised before it is eaten, or pancreatin may be given in keratin- 
coated pills designed to remain undissolved until they have reached 
the small intestine. The stools should be watched for undigested 
particles of food, muscle fibres, etc. 

If emaciation continues with an exclusive diet of animal food, it 
may be best to give oatmeal porridge or mush which is predigested 
with diastase or malt extract. Baked potatoes may be similarly 
treated. 

Foods to be avoided are very rich milk, green vegetables, raw 
acid fruits, dried fruits and nuts, richly cooked acid or fat dishes, 
crustaceans, pork, veal, coarse bread, pastry, sweets, and desserts of 
all kinds. 

In milder cases in which there is more or less constipation with 
intestinal catarrh, it is important to regulate the bowels, and this 
may be done in part by the character of the food, also by system- 
atic exercise, both active and passive. Mild calisthenics, massage 
of the limbs and the abdominal wall, combined with abundant fresh 
air, daily bathing in cold water, and friction of the skin, are all use- 
ful aids to treatment. 

There are cases of chronic colitis in adults which do not improve 
upon any diet, and after trying a great variety of foods the patients 
seem to get on even better for a time on a mixed diet of consider- 
able diversity. 



562 DIET IN DISEASE 

Alcoholic stimulants should be given, and the best forms are 
claret, sherry, or brandy, all diluted to two or three times their 
bulk with Apollinaris or plain water. See recommends the Tannin 
Wine of St. Raphael. 

Some patients are considerably benefited by residence for a few 
weeks at one of the alkaline mineral springs. 

Chronic Intestinal Indigestion in Children 

Chronic intestinal indigestion in children should be treated by 
dieting rather than by medicines. Diligent inquiry must be made 
into the cause of the trouble, and the diet must be regulated ac- 
cordingly. The stools and the urine must always be carefully ex- 
amined. If the former are hard, white, and lumpy, if they are too 
loose and contain undigested coagulse of casein and drops of fat, or 
if they are sour from lactic-acid fermentation, the milk is certainly 
disagreeing. If the child is nursing, the mother's milk may be at 
fault. If the woman is worried, exhausted, or possibly pregnant, or 
suffering from insomnia, menstrual disorder, phthisis, or other 
chronic ailment, or if lactation is too long continued, her milk must 
be replaced by that of a good wet nurse, or, failing this, by the bot- 
tle. This change will often cure the indigestion at once. It may 
be that the infant is simply overfed, or fed too often. The excess 
of milk fails to be absorbed, undergoes lactic-acid fermentation, 
produces gas with abdominal distention and diarrhoea or irregular 
passages, together with loss of weight, fretfulness, and other symp- 
toms. If the child is being fed upon a mixed diet with milk and 
one of the prepared infant foods, such as Mellin's, Ridge's, Horlick's, 
etc., the difficulty may be with either the proteid or the carbohy- 
drate elements, but the prepared foods had better be abandoned. 
It is easy to ascertain which is at fault by confining the diet ex- 
clusively for a few days to one or the other of these classes of 
foods, and noting the effect on the bowels. Moreover, proteid in- 
testinal indigestion usually produces offensive alkaline feculent 
stools, while carbohydrate indigestion causes acid stools with more 
flatus. Of course both classes of indigestion may coexist in the 
intestine, but the difficulty is primarily with one sort or the other, 
and hence the advantage of substituting for the mixed diet a more 
elementary one. In place of milk, egg albumin, pressed-beef juice, 
or meat broths are to be given. Or if these proteids are not di- 
gested, the diet should consist for a few days of barley or rice 
gruel, or gruels of " torrefied starch " — i. e., wheat flour which has 
been boiled or roasted in order to burst the starch granules and 
partially convert the granulose into dextrin. The digestion is carried 
still further by the use of diastase or malt extract, or malted milk 
may be given. 



THE ALIMENTARY CANAL 563 

A mixture of cream and water (p. 486) is well tolerated in 
some cases, or peptonised milk and various other preparations of 
milk may be given; but at present peptonised milk is less in vogue 
than formerly, as its power of restoring emaciated tissues has been 
seriously called in question. " Modified " or " humanised " milk is 
to be preferred (p. 88). 

Older children may have beef or chicken jelly, scraped beef, 
etc. It is well to avoid monotony of diet, lest the appetite fail 
entirely. 

Chronic Gastro-intestinal Catarrh — Chronic Entero- 
colitis — Chronic Diarrhcea in Children 

These conditions in children should be treated by very careful 
regulation of the diet. Parents are apt to be ignorant in regard to 
this matter, and strict written rules should be furnished to them. 
Children should be fed at regular intervals at least four times a 
day, in order that the quantity of food given each time may not be 
too much. They must not be given acid food, such as pickles, or 
indigestible substances of any kind, or fruit. Many cases do best 
when put upon a plain milk diet for several weeks, or, if this is not 
expedient, peptonised solutions or pancreatinised food may be sub- 
stituted in part. Other good temporary substitutes for plain milk 
are buttermilk, whey, and koumiss. Beef broth should not be given 
exclusively, on account of its occasional tendency to increase diar- 
rhcea. If the stools contain much fat it is an indication that the 
pancreatic and biliary secretions are deficient, and the use of pan- 
creatin is then of special service. 

These children cannot digest sugars, starches, or fats very thor- 
oughly, although cod-liver oil may be assimilated, and when it is 
it constitutes a valuable food. It does not necessarily increase 
diarrhcea, and it may even check it indirectly by improving nu- 
trition. 

Among foods which may be allowed to older children as im- 
provement begins are raw oysters, boiled or broiled fresh fish, 
minced beef and chicken, soft-cooked eggs, soda crackers, bread 
and milk, toast, thin bread and butter, blancmange, custard, junket, 
and wine jelly. Sometimes the child continues to emaciate upon a 
diet of animal broths and meats, and fails to digest either eggs or 
milk. In such cases pancreatinised mush or some simple cereal, 
such as barley or rice, may be given with malt extract, and among 
vegetables which may sometimes be allowed, if diarrhoea has ceased, 
are asparagus, spinach, stewed celery, cauliflower, and thoroughly 
baked potatoes with a little salt and butter well mixed. 

Hot water should be recommended before meals if the child will 
take it. It may be given a faint flavour of some spice, such as 



564 DIET IN DISEASE 

cinnamon or clove, and whey is an excellent beverag-e. Some chil- 
dren become very fond of koumiss, but it is expensive unless home- 
made (p. 81). 

Many of these children become strikingly emaciated, and, in 
spite of all dietetic regimen, the skin is dry and wrinkled, and care. 
should be taken to improve its nutrition. This may be done by 
tepid baths before bedtime and gentle friction, and by inunctions of 
three or four drachms of warm melted cacao butter or warm olive 
oil or cod-liver oil, to be rubbed in over the extremities and parts of 
the trunk other than the abdomen. In this way little if any nour- 
ishment can be rubbed into the circulation, and the main benefit of 
the inunction consists in improving the condition of the skin by local 
action, and in preventing excessive heat loss, to which poorly nour- 
ished children are prone. 

Massage should be given for a quarter of an hour every morning. 
It may be applied over the entire body, unless there is much diar- 
rhoea, when the abdominal wall should be omitted. 

Simple Atrophy — Marasmus 

Marasmus is a form of starvation occurring chiefly in artificially 
fed infants, but also in those at the breast, in whom there is great 
wasting of the muscular and other soft tissues, and sometimes 
catarrh of the alimentary canal. The food is either too limited in 
quantity, is indigestible, or else is supplied in a form in which the 
ingredients are not properly balanced. Breast-fed children are more 
apt to suffer from insufficient quantity, and hand-fed infants from 
improper quality of food and overfeeding. " Food upon which a 
child has thrived for three or four months, perhaps, can become 
unsuitable, and consequently lead to wasting if the digestive powers 
be suddenly reduced by an intercurrent disease " (Louis Starr). 
The treatment of marasmus is therefore essentially dietetic, and 
the reader is referred to the general directions for infant feeding. 
No detail should be considered too trivial for the physician's per- 
sonal attention. If nursed, the mother or wet nurse's milk should 
be examined for richness in cream and curd. If hand-fed, the most 
scrupulous care must be taken to secure antiseptic cleanliness, and 
milk or milk and meat juice should be the staple foods, to the exclu- 
sion of all farinaceous articles and patent " baby foods." The dis- 
ease is commonest in the first year of life, but may occur in the sec- 
ond, and its effects in enfeebling the constitution may last much 
longer. It is just at this period that mothers — for reasons of sup- 
posed economy or expediency — are tempted to supplant the only 
natural infant food (milk) with all sorts of prepared foods. It is 
because they do not know how to prepare cow's milk properly and 
adapt it to the baby's needs that they substitute or add artificial foods. 



THE ALIMENTARY CANAL 565 

All milk should be peptonised or Pasteurised (p. 78), and 
lime water or barley water are the best diluents, the former being 
preferred if there is vomiting or acid eructation. (For the correct 
degree of dilution according to age, see Infant Feeding.) If good 
top milk cannot be obtained, one or two tablespoonfuls of cream 
with a teaspoonful of milk sugar is to be added to each bottle. Some 
infants do better for a shctrt time upon a cream-and-water mixture. 

In other cases all milk should be withheld, and expressed-beef 
juice, diluted meat broths, and egg-albumin solution must be used. 
Louis Starr says : " At eight or ten months from two to four fluid 
ounces of thin mutton or chicken broth free from grease may be 
allowed each day in addition to the milk ; at twelve months the yolk 
of a soft-boiled egg, rice and milk, and carefully mashed potatoes 
with gravy; and at the end of the second year a small quantity of 
finely minced meat." 

Cod-liver oil should be given, but never until the digestive func- 
tions are well restored, as shown by the character of the stools, the 
absence of eructation and flatulence, and a clean tongue. It is to 
be prescribed pure, or in one of the emulsions with calcium lacto- 
phosphate. 

Daily warm baths and inunctions of two or three drachms of 
cod-liver oil, or, better, olive oil, are to be ordered, with fresh air in 
abundance. 

Mucous Disease— Chronic Pseudo-membranous 
Gastro-enteritis — Membranous Enteritis 

Pathological Physiology. — Mucous disease is an obstinate chronic 
affection in which large quantities of thick, ropy mucus are formed 
in the alimentary canal, but chiefly in the large intestine. The dis- 
ease is accompanied usually by neurasthenia and disorders of gastric 
and intestinal digestion and absorption, of greater or less severity. 

In the disease called membranous enteritis a similar condition is 
present, and the hypersecretion results in the formation of long tube 
casts of fibrinous mucus. The passage of the casts is sometimes 
accompanied by severe paroxysmal pains, and blood may appear in 
the stools. Although they may be separated clinically, the dietetic 
treatment of these two affections is the same. Young children nor- 
mally secrete more mucus from the intestines than do adults, and 
the long continuance of an irritating diet of improper food may 
give rise to hypersecretion. Chronic mucous disease is sometimes 
a sequel of the infectious diseases which particularly affect children, 
notably whooping cough. There are a larger number and variety of 
bacteria found in the stools than are usually present, but this disease 
is not definitely attributable to the action of any one species. The 
disease is also sometimes associated with intestinal worms. 



566 DIET IN DISEASE 

Symptoms. — The appetite is very irregular. It may be exag- 
gerated early in the disease, and fail completely later on. The food 
does not nourish the child, absorption being prevented by the mu- 
cus, and it causes flatulency and discomfort. Emaciation is pro- 
gressive and extreme. Some of the stools consist wholly of mucus, 
fatty epithelial cells, and granular detritus, while others contain 
particles of undigested food, milk curds, meat fibre, etc., mixed with 
mucus. 

Dietetic Treatment. — The only hope of cure of this condition 
lies in the most rigid dietetic treatment, combined with regular 
habits, bathing, etc. In the worst cases only predigested fluid food 
should be given, such as pancreatinised milk, meat juice, and egg 
albumin. Beef tea, light broths of veal, mutton, or chicken, con- 
somme, or milk punch may be allowed. 

Sometimes it is necessary to give no food by the stomach for six 
or eight hours, and then commence to feed very slowly, giving tea- 
spoonful doses at fifteen-minute intervals. If the child has been 
living for long upon milk alone, and the stools show fat and undi- 
gested curds, it is best to make a radical change and proscribe it en- 
tirely. Jacobi gives instead a mixture containing five ounces of bar- 
ley water, one to two drachms of brandy or whisky, the white of an 
egg, and a little salt and cane sugar. Dose, a teaspoonful every five 
or fifteen minutes. This is a fairly palatable mixture. It is con- 
sidered best to withhold all farinaceous and saccharine articles until 
some sign of improvement appears. 

Edwards prescribes the dietary of the London Northeastern Hos- 
pital for Children. (See Hospital Dietaries.) 

Dysentery 

During an attack of acute dysentery the patient should be kept 
absolutely quiet in bed, and should not be allowed to rise for the 
movement of the bowels, making use of a bedpan instead. Through- 
out the active stage the diet must be strictly confined to easily di- 
gestible food, and in most cases it is wisest to give only predigested 
fluid articles. Peptonised or pancreatinised milk, or boiled milk, 
pressed-meat juice, whey, or raw egg albumin beaten with sherry 
and flavoured with nutmeg are recommended. Many patients do 
best upon a diet of raw scraped beef or meat balls (p. in). 

In cases of acute dysentery, and especially in the amoebic form, 
the loss of strength, anaemia, and emaciation progress very rapidly, 
and the strength must be supported by stimulation, for which brandy 
is preferable to whisky. 

During convalescence the diet must be very cautiously increased, 
and confined to food which is promptly and completely digested, 
leaving but little residue. For this purpose animal food should be 



THE ALIMENTARY CANAL 567 

chiefly eaten, while fish, tender beefsteak, roast beef, boiled or 
broiled chicken, eggs, custard, blancmange, dry toast, junket, well- 
boiled rice, or wine jelly, may be given. All fruits and vege- 
tables must be forbidden, and butter and cream should be taken 
sparingly. 

If the disease occurs in infancy, the child, if possible, should be 
fed at the breast. Otherwise all milk given should be Pasteurised. 
Beef tea and mutton broth may be allowed in moderation, and 
special care should be observed not to overfeed. 

CHRONIC DYSENTERY 

Chronic dysentery is often best treated by an exclusive milk 
diet of from two and a half to three quarts a day, with rest in bed 
or on the lounge. In other cases rare steak or roast beef or chicken 
and egg albumin may be allowed, with dry toast, zwieback, or crack- 
ers. The milk and meat diet may be advantageously combined. 

In Osier's opinion, if there is much ulceration of the colon meat 
is not well borne, and it is better to keep the patient upon a diet 
which will give but little residue, such as boiled or peptonised milk. 

The stools must be examined every day or two to ascertain the 
presence of undigested fragments of milk curds or meat, oil globules, 
mucus, blood, etc. If improvement does not occur, the patient may 
be put upon a diet of egg albumin with beef juice, or some of the 
preparations of beef meal (p. in) or peptonoids, with pancreatin- 
ised milk. Return to solid diet must be very gradual, and may be 
conducted on the lines directed for convalescence from typhoid fever 
(P. 435)- 

Acute Intestinal Obstruction 

Many of these cases demand immediate operation, but if for any 
reason this is not performed nothing should be given by the mouth. 
If any food be taken it decomposes, and even drink may excite 
severe vomiting. The patient may be nourished by the rectum, 
and thirst can be relieved by injection of a pint of lukewarm 
water with a teaspoonful of salt into the rectum. If the latter is 
irritable a smaller quantity should be employed, and more fre- 
quently given. Another method of relieving thirst is to inject a 
pint or two of warm, sterilised salt solution of the above strength 
into the cellular tissue beneath the skin, after the manner of the 
hypodermoclysis recommended in cholera (p. 448). If necessary, 
half an ounce or more of whisky is to be given from time to time 
hypodermically, weakened by two or three times the quantity of 
salt solution. If all these injections are sterilised and inserted 
deeply they are much less painful than if inserted immediately be- 
neath the skin. 

If the obstruction is overcome without operation, the diet should 
33 



568 DIET IN DISEASE 

be very slowly increased, giving only fluid nourishment by the 
mouth for two or three days, or until all symptoms have subsided. 

The fluid food should consist of beef juice, broths, egg albumin, 
and simple farinaceous gruels. Milk, if not wholly absorbed, forms 
too bulky feces. 

The symptoms of profound collapse, thready pulse, etc., depend 
not upon the local condition of obstruction, but upon sapraemic 
intoxication from toxins produced by decomposition of retained 
food. This statement is corroborated by the prompt relief which 
sometimes succeeds emptying the bowel after removal of the ob- 
struction and the use of lavage and irrigation with warm water 
(io6° F.). 

Chronic Constipation 

Physiology. — The periodic daily evacuations of the bowels are 
determined by peristaltic contractions of the muscular wall of the 
intestines excited by their contents. The thick fluid condition of 
the food (chyme) which enters the small intestine from the stomach 
is gradually altered by absorption of water and soluble ingredients 
in the small intestine. This process is accomplished by rhythmical 
vermicular contractions of the intestinal wall which are reflex in 
character and stimulated in different degrees by the bulk and chem- 
ical combination of the food and by the various digestive secretions, 
namely, the intestinal and pancreatic juices and, especially, the bile. 
The peristalsis is more active in the small than in the large intestine, 
for it has the triple function of (i) mixing the food and digestive 
fluids ; (2) bringing the whole mass into contact with a large surface 
for absorption ; and (3) propelling the residue towards the large 
intestine. 

Simultaneously the local blood current is increased. The vessels 
and lymphatics in the intestinal wall and mesentery become greatly 
distended by absorption of food products. The increase in volume 
and flow of the blood also stimulates peristaltic contractions. 

Towards the lower end of the small intestine the food is found 
diminished in volume by absorption, and the mass is consequently 
somewhat drier. The ileo-csecal valve is periodically relaxed by 
reflex mechanism, and the peristalsis of the small intestine propels 
the food onward into the large intestine, where further absorption 
takes place, and the residue is more slowly moved towards the sig- 
moid flexure. Here it remains and accumulates until a certain bulk 
is gathered, which by pressure or distention excites the reflex mech- 
anism of defecation. This mechanism employs a large number of 
muscles, and hence the need of a controlling nerve centre, which 
is found in the lumbar region of the spinal cord. 

Constipation, when not due to intestinal obstruction, is dependent 
upon lack of peristalsis, as diarrhoea is due to excessive peristalsis. 



THE ALIMENTARY CANAL J 569 

Many persons are wholly ignorant of what constitutes a normal 
stool. The custom of using patent water closets often prevents 
them from seeing the stool, and they are unable to correctly esti- 
mate its amount or character. A little accumulation of residue left 
over each day will presently cause very uncomfortable constipa- 
tion. The normal stool should weigh about five or five and a half 
ounces, of which only one and a half ounce is solid matter. It 
should constitute a sausage-shaped mass, in all about six inches 
in length. 

Pathological Physiology. — Constipation may result from one or 
more of the following causes, which are related to diet: 1. Insuf- 
ficient quantity of solid food. 2. Too highly nutritious or concen- 
trated food. 3. Insufficient fluid. 4. Astringent food and drinks. 
5. Indigestible food. 6. Lack of digestive fluids. 7. Irregularity in 
diet. 8. Obstruction from overeating. 9. Lack of peristalsis. 10. 
Lack of exercise. 

1. Insufficient food is one of the most common causes of consti- 
pation. In prolonged starvation the bowels cease to move entirely. 
Persons who eat but sparingly have too little bulk of food to excite 
the normal peristaltic motion of the intestines, and the waste prod- 
ucts accumulate in consequence. 

2. Too highly nutritious or concentrated food, such as richly 
seasoned meats, milk, meat extracts, peptonised fluids, etc., when 
almost completely absorbed, leave insufficient residue of waste mat- 
ter. Peristalsis is therefore either not excited or the contracting 
intestinal wall has insufficient bulk of material to seize upon and 
propel. 

3. Insufficient fluid often causes constipation, and for three rea- 
sons : (1) The chyme is not kept liquid enough to be thoroughly 
mingled with the digestive juices. (2) The intestinal walls become 
too dry and friction over the hardened fecal masses is increased, 
making it difficult to propel them. (3) There is less fluid absorbed 
by the blood, and consequently the digestive juices and intestinal 
mucus are reduced in amount and altered in quality. 

4. Astringent food or drinks, such as tea, brandy, or claret, con- 
stipate by checking the mucous and other secretions, thereby in- 
creasing friction within the intestinal wall. 

5. Indigestible food may be so hard and bulky as to be imper- 
fectly acted upon by peristalsis and incompletely mingled with the 
digestive juices, or it may give rise to abnormal fermentation and 
production of substances which inhibit absorption and peristalsis. 

6. Lack of digestive fluids in normal proportion or serious alter- 
ations in their composition retard digestion and lessen peristalsis. 

7. Irregularity in diet or in the intervals of taking food, eating 
too hastily, imperfect mastication, and great variations in the quan- 
tity of food eaten, all tend to disorder digestion by disturbing the 



570 DIET IN DISEASE 

natural rhythm of its various stages, and especially the periodicity of 
defecation. 

8. Obstruction from overeating, particularly in children, may 
cause constipation from the accumulation of larger quantities of 
waste matter than the intestinal muscles have power to propel. 

9. Lack of peristalsis occurs through enfeebled intestinal muscles 
or imperfect nerve stimulation. 

10. Lack of exercise fails to stimulate the circulation, both gen- 
eral and local, and to secure the abundant oxygen supply needed for 
complete oxidation of the food. It also fails to stimulate peristalsis 
by the natural movements of the body, especially of the abdominal 
muscles, and by increasing the flow of bile. 

Constipation is not infrequently a constitutional habit or family 
peculiarity, running through several generations. It is provoked 
by sedentary habits and neglect of the calls of Nature, and it is 
the usual accompaniment of impoverished conditions of the blood 
and malnutrition, and especially anaemia, neurasthenia, hysteria, 
and chronic diseases of the liver and stomach. It is also fre- 
quently present in connection with acute fevers, and the habit of 
the perpetual consumption of drugs of many varieties may occa- 
sion it. 

Weakness of the muscles of the intestinal and abdominal wall are 
common factors in the production of constipation. This symptom is 
therefore present in obesity, overdistention of the abdominal wall 
during pregnancy, and in atony of the large intestine and chronic 
diseases of its mucous membrane. It is also produced by obstruc- 
tion from the pressure of tumours, accumulation of scybalae from 
impaction of foreign bodies in the bowel, stricture, and localised 
atony of the sigmoid flexure. 

Symptoms. — In all common cases the symptoms accompanying 
constipation are debility and lassitude, while more or less mental de- 
pression is present in persons of nervous or hypochondriacal temper- 
ament. When it occurs in the course of chronic insanity it increases 
languor, moroseness, and irritability of temper, and not seldom ex- 
cites acute and violent symptoms. As a result of the accumulation 
of waste matter in the lower bowel, internal misplacements may oc- 
casionally result, or, if they already exist, they may be increased. 
Sacral neuralgia is sometimes produced, and hemorrhoids from con- 
gestion of the rectal veins may occur. Occasionally constipation 
may result from malformations of the intestine — adhesions which 
bind loops and coils of the intestine in abnormal positions and inter- 
fere with peristaltic movement. The impacted feces accumulate in 
the colon and are found chiefly in the sigmoid flexure, but they may 
also form large tumours in the hepatic or splenic flexure, or even in 
the right inguinal region. In aged persons sacculi of the colon 
may become permanently distended, and scybalae become calcified 



THE ALIMENTARY CANAL 571 

as enteroliths. A channel is sometimes bored through the impacted 
masses of fecal material, and the long-continued constipation will 
give rise to diarrhoea. The fecal mass acts as a local irritant, and 
diarrhceal stools pass through the channel. 

Chronic constipation may sometimes give rise to acute attacks of 
localised pain and considerable fever (104 F.). These attacks may 
simulate appendicitis, localised peritonitis, or other acute abdominal 
diseases. 

Dietetic Treatment. — Before ordering the diet for chronic con- 
stipation, the patient must be minutely interrogated as to his daily 
habits of life, such as occupation, hours for meals and for exercise, 
recreation, and sleep, the kinds of foods and quantity usually eaten, 
the amount and kinds of fluids drunk, hour for going to stool, the 
use of stimulants and tobacco, and presence of mental worry or 
anxiety. 

The principles of dietetic treatment of chronic constipation are 
based upon supplying digestible food, which will excite peristalsis 
either by its bulk or its physical and chemical properties. Vegetable 
food in general, as distinguished from nitrogenous diet, furnishes a 
much larger proportion of waste matter. Herbivorous animals have 
more abundant evacuations than do carnivores. 

Following is a list of common foods discussed in their relation 
to constipation : 

Vegetables. — The cellulose of starchy foods is difficult of diges- 
tion and of comparatively little nutrient value for man ; hence it 
yields a considerable quantity of waste material. This is true of 
the starch granules of potatoes, corn, peas, beans, etc. 

Other vegetables which leave a large residue after digestion are 
tomatoes, spinach, lettuce, asparagus, salsify, cabbage, and celery. 
Tomatoes and spinach seem to possess slight special laxative proper- 
ties. Spanish onions, boiled, are laxative. 

Cereals. — The various cereals used for bread when coarsely 
ground contain a large proportion of the external envelope of 
the grains, which is more or less hard and rough, and by its pres- 
ence in the intestine it stimulates peristalsis through mechanical 
irritation. 

For the above reasons the following articles of diet tend to over- 
come constipation : Coarse Graham bread, rye bread, wheatena, 
wheaten grits, cornmeal, Indian meal, oatmeal, brown or " whole- 
meal " bread, Boston brown bread, shredded wheat. 

Molasses and honey added to bread are laxative. Gingerbread, 
especially for children, is sometimes efficacious. With some per- 
sons the substitution of milk sugar (lactose) for cane sugar proves 
laxative. 

Beverages. — Coffee, beer, cider, and unfermented grape juice are 
somewhat laxative. 



~$J2 DIET IN DISEASE 

Oils. — Olive oil and cod-liver oil, if taken at bedtime into an 
empty stomach, are laxatives for some persons, particularly children. 

Adults may take a dessertspoonful of best Lucca oil with each 
meal, eating it with fresh vegetables, such as beets or lettuce, or 
mixing it with potatoes. 

Fruit. — Fruits are laxative, either because they contain indiges- 
tible seeds, which act mechanically in the intestine (e. g., figs, ber- 
ries), or because the vegetable acids and salts which they furnish 
upon being absorbed stimulate the digestive secretions and peri- 
stalsis. 

Fruits with seeds are laxative, such as figs, blackberries, straw- 
berries, huckleberries, blueberries, and also grapes in large amount 
without the seeds. 

Fruits having special laxative properties through chemical action 
are apples, pears, peaches, oranges, shaddock, cherries, prunes, 
plums. Many fruits act in both the above ways, and raisins, figs, 
prunes, and apples leave considerable bulk of waste matter after 
digestion. 

Fruit is always more laxative when eaten between meals or 
some time — say, half an hour — before breakfast. It then enters the 
intestine more promptly, and it is not retarded in its effect by the 
presence of other articles of diet. Its action is furthered by drink- 
ing a tumblerful or two of water. 

With many persons constipation may be prevented by eating one 
or two oranges or the juice of half a grape-fruit before breakfast. 
The latter is very sour, and considerable sugar is required to make 
it palatable. This is a decided disadvantage for those who have 
flatulent dyspepsia or gout. Instead of sugar, the bitterness may be 
disguised by a little sherry or rum poured upon the cut fruit. A 
half dozen dried figs or a dozen or so of French prunes eaten at in- 
tervals during the day, when the stomach is empty, produce a laxa- 
tive effect. These fruits in smaller quantities are very good for 
children. In some cases the breakfast may be confined exclusively 
to fruits for two or three months. 

Cooked Fruits. — With many persons having imperfect digestion 
raw fruits disagree, and since their laxative properties are not much 
weakened by being cooked, it is better to eat them in that form. 
Stewed prunes, or apples either stewed or baked, are very easy of 
digestion, and the latter may often be eaten by invalids in whom 
the digestive organs are very weak. Cooking berries or other suit- 
able fruits by stewing renders them much more digestible, and 
does not impair their nutritive qualities. The principal objection to 
cooked fruits is that they usually require so much sugar to make 
them palatable that they may cause flatulency. A little bicarbonate 
of sodium will neutralise the acidity, and saccharin may be added 
instead of sugar. 



THE ALIMENTARY CANAL 573 

Canned or dried fruits and fruits preserved in sirups are of little 
value for constipation. 

A few fruits, like the banana, are apt to cause constipation. 

Owing to the prevalent idea that fresh fruit relieves constipation, 
patients occasionally eat too much of it, with the result of producing 
dyspepsia and increasing their original trouble. 

Nuts. — Nuts, especially English walnuts and almonds, are excel- 
lent laxatives, partly from their bulky residue and in part from the 
oils which they contain. 

Water. — Copious draughts of either very hot or cold water, two 
or three tumblerfuls, should be taken before retiring and on rising. 
Many persons, from a belief that water drunk with meals is injurious, 
abstain from it and forget to take fluid between meals, and become 
constipated in consequence. If they happen to lose water by free 
perspiration also, the difficulty is enhanced. Such patients should 
be advised to drink water freely, as above indicated. It also aids 
digestion to take a tumblerful of hot water about an hour after a 
meal unless the gastric juice is feeble in strength of acidity. The 
stomach contents becoming somewhat thickened by loss of fluid 
through the pyloric orifice or by direct absorption through its own 
wall, are better digested by being diluted again. The temperature 
of the water drunk makes but little difference as far as constipation is 
concerned. Cold water is warmed and hot water is cooled by the 
oesophagus, so that upon reaching the stomach it is nearly of the 
normal body temperature, no matter how much it differed from this 
when swallowed, provided it has been taken slowly. If swallowed 
in large draughts it does affect the stomach temperature for a few 
moments, but it is soon brought to the normal body temperature 
again (p. 334). 

When patients will not drink enough plain water, they can be 
induced to take lemonade or water flavoured with some aromatic. 
A few cloves put in a tumbler of boiling water and allowed to steep 
overnight impart their flavour to the fluid, which may be drunk on 
rising in the morning. 

Summary of the most Useful Articles for Chronic Constipation. — 
Abundant water, coarse brown or bran bread, oatmeal, butter, fresh 
green vegetables (lettuce, spinach, sprouts, rhubarb, etc.), prunes, 
figs, apples (cooked or raw), peaches, berries, buttermilk, apple cider, 
koumiss, honey, English walnuts. 

Foods to be Avoided. — Persons suffering from habitual constipa- 
tion do well to give up the following articles : Eggs, milk, sweets, 
pastry, puddings made of simple amylaceous substances — such as 
rice, sago, etc. — fried foods, rich gravies, sauces, curry, strong 
condiments, pickles, cheese, tea, sour or red wines. 



574 DIET IN DISEASE 



AIDS TO DIETETIC TREATMENT 

It is an important and infallible rule in cases of chronic constipa- 
tion that hygienic as well as dietetic treatment should supersede the 
use of medicine. It is very necessary to establish a uniform hour 
for going to stool each day, and all efforts at straining should be 
avoided. Exercise in moderation should be insisted upon, such as 
walking at least an hour or two twice a day, but of exercise in the 
open air, horseback riding is by far the most beneficial. One or 
two rides a week are much better than none. Many persons find 
improvement from bicycling. Tight lacing and constriction of the 
abdomen by tight belts should be avoided, and also sitting long in 
positions compressing the abdomen. Much good may be accom- 
plished by elementary instruction in calisthenics, in which special 
attention is paid to deep respiratory movements of the diaphragm 
and abdominal muscles. 

Regularity should be observed in habits of life, in hours of sleep, 
and of meals. Many business men whose daily routine of early 
rising, exact hours, and evening dinners is disturbed on Sundays by 
late breakfast and a noon dinner, find that the regular habit of the 
bowels is interrupted at the first of the week, and in consequence 
may suffer for a day or two from headache and " biliousness." 

Massage. — Massage is the process of manipulating the muscles 
and subcutaneous cellular tissue. The aim of the treatment is to 
mechanically compress and stimulate the structures beneath the 
skin, and it is to be distinguished from the effects of merely rubbing 
the surface of the body, which acts through excitation of the cuta- 
neous nerves and circulation. 

Massage promotes the movement of the blood through the veins 
and of the lymph in the lymph spaces and capillaries, and favours 
the removal of waste products from the tissues compressed, and the 
increase of healthy metabolism in the muscles. It also stimulates 
the latter in a slight degree to contraction. It aids the functional 
activity of the liver, stomach, and bowels. The various manipula- 
tions are complex, and when rightly performed require the skill and 
experience of thoroughly trained operators. The chief manipula- 
tions are classed as — 

1. Percussion by short quick blows of the fingers or small rubber 
hammers. 

2. Rolling the muscles and subcutaneous tissues beneath the ex- 
tremities of the fingers. 

3. Kneading with the fingers and palms of both hands, placed 
one above the other, on the patient's arm or leg. 

Massage of the abdominal muscles is most useful for constipation, 
and both percussion or mechanical vibration and kneading are to be 
used. It should be performed in the direction of the colon, com- 



THE ALIMENTARY CANAL 575 

mencing low down on the right side of the abdomen, ascending to 
the ribs, crossing to the left, and descending upon the left side to 
the sigmoid flexure. This mechanical movement not only pushes 
along the intestinal contents, if the abdominal wall be not too fat 
or rigid, but it stimulates peristalsis by reflex action. If possible, 
it should be given in the morning before rising, and at first daily, 
for fifteen or twenty minutes, but later every other day. The treat- 
ment should be continued for a month or more. Obstinate cases 
have been cured in this manner, and the method is especially serv- 
iceable for very obese patients. 

Some persons derive aid from manipulating the abdominal wall 
for themselves while lying in bed in the morning. A large wooden 
ball like a croquet ball or a heavy metal ball weighing four to six 
pounds may be rolled over the abdomen for five or ten minutes 
every morning, pressing it in deeply in the direction of the colon. 
This sometimes, in thin subjects, promotes the movement of the 
intestinal contents. 

Medicines. — Discussion of the medicinal treatment of constipa- 
tion is not within the scope of this work, but the practice of contin- 
ually taking laxatives and strong cathartics cannot be too strongly 
condemned. The constant daily overexcitation of the bowels by 
such remedies as aloes produces a deplorable condition in which the 
bowels refuse to act at all without constantly increasing dosage. 

The majority of such cases can be cured by diet, but the rules 
must be very distinctly laid down, and the patient must exercise 
patience and care in adhering to them. I have sometimes been able 
to relieve patients who for several years had depended wholly upon 
strong cathartic pills or enemata, by stopping all medicine, and en- 
forcing simple dietetic rules, especially in regard to drinking abun- 
dant fluid and eating laxative and bulky food. They often think 
that a daily movement is absolutely necessary, and the worry and 
nervousness which its absence occasions increases the difficulty. 
They should be reassured, and told not to be concerned if the 
bowels do not move at first for two or three or even four days, and 
that if they do not have an unaided passage in that interval they can 
certainly be relieved, and diet and regimen will succeed in time if 
persistently followed. 

In very obstinate cases when diet does not succeed alone, atten- 
tion to its regulation will enable the patient to obtain the desired 
result with mild and decreasing doses of simple saline laxatives such 
as Congress, Crab Orchard, Mt. Clemens, Apenta, or Rubinat water, 
in lieu of strong cathartic pills, or patent medicines. 

Tobacco. — Tobacco smoking increases peristalsis. Some men 
become constipated when deprived of their after-breakfast cigar. 
The effect of tobacco is not constant, however, and by disordering 
digestion too much smoking may be an indirect cause of constipa- 



5/6 DIET IN DISEASE 

tion. In those in whom it acts favourably upon the bowels, a good 
cigar is usually more active than any other form of the weed. 

Bathing. — A daily morning cold bath followed by vigorous fric- 
tion of the skin is of great service. 

Electricity. — Faradisation of the abdominal walls is frequently 
useful, but, owing to the fact that the electric current when applied 
superficially radiates over the skin without penetrating to any ex- 
tent beneath the surface, it cannot be expected to reach the intes- 
tinal wall. Any benefit derived from such application must be purely 
of a reflex character from excitation of the cutaneous nerves trans- 
mitted through the cord to the sympathetic nerves. A much better 
method of applying a faradic current consists of introducing one 
electrode for several inches into the rectum, while the other is 
moved about over the surface of the abdominal muscles. In this 
manner these muscles may be made to contract and move the intes- 
tines to some extent, and it is possible for a portion of the current 
to pass through the sigmoid flexure. If carefully adjusted, the ap- 
plication of the current gives rise to no pain or discomfort. 

Bandaging. — In very obese persons, who are liable to suffer 
from constipation, the pendulous and relaxed abdominal wall should 
be supported with an abdominal bandage. The same treatment may 
give comfort when the wall is much distended in childbearing or by 
the presence of large abdominal tumours or accumulations of ascitic 
or ovarian fluid. 



Constipation in Infants and Children 

In earliest infancy from two to three daily evacuations from 
the bowels are considered a normal number, but in childhood, as 
in adults, one passage is normal. In later infancy constipation is 
exceedingly common on account of the milk diet, and bottle-fed 
babies are more subject to it than sucklings. The small intestine 
is relatively longer than in the adult, the large intestine easily 
becomes distended, the pelvis is more contracted, and peristalsis 
is usually less vigorous, owing to a less powerful musculature than 
obtains in adults. 

When constipation is present in an infant at the breast the milk 
may be too rich in casein and deficient in fat, salts, and sugar. This 
may be due to a constipated habit of the mother, and laxative foods 
should be given to her rather than medicines to the child. If the 
child is nursing a wet nurse, it may be best to change to another in 
perhaps an earlier stage of lactation, or one whose milk is less rich 
in proteids. 

If the infant's stools consist of dry and brittle scybalse it should 
be given more water to drink, or a little oatmeal water, which 
is laxative. Other simple and oftentimes effectual remedies are 



THE ALIMENTARY CANAL 577 

from half to a teaspoonful of olive oil, molasses, melted sugar, or 
butter. 

In the case of hand-fed babies when the milk forms large and 
hard curds, and when the proportion of cream is too small, the addi- 
tion of water and cream will often remedy the evil. 

As an occasional, but not habitual, simple remedy for constipa- 
tion in such cases relief may be obtained by making a mixture of a 
tablespoonful of whole-meal gluten flour in a pint of water, boil- 
ing for three hours to a thick mass, and adding a teaspoonful of the 
mixture, unstrained, to each feeding bottle. 

Artificial foods, " prepared " foods, and condensed milk are more 
apt to excite diarrhcea than constipation, but it should be remem- 
bered that they may cause the latter, and the continued use of 
coarse food or cathartics, or of large enemata, overstimulates the 
bowel and results in constipation. 

When it is necessary to use enemata they should be small, and 
not too frequently given. From ten to thirty drops of glycerin in 
two teaspoonfuls of water is quite sufficient for a young nursing 
infant. The glycerin, by virtue of its hygroscopic power, abstracts 
water from the rectal mucous membrane, causing hypersemia, which 
in time excites peristalsis. A simple injection of two teaspoonfuls 
of cold water containing a pinch of salt is often successful. 

Suppositories may also be used. They should be small, conical 
in shape, and well oiled before being inserted. They may be made 
of glycerin, soap, molasses candy (Fruitnight), or gluten. 

For older children, from three years up, some one or more of the 
following articles should be included in the menus. By this means it 
will be possible to do without castor oil, senna, rhubarb, strong ene- 
mata, and other remedies which are constantly abused. 

Foods Recommended.— Oatmeal, corn bread, cracked wheat, por- 
ridge, wheaten bread made of unbolted flour, bran bread soaked 
in warm milk, gingerbread, bread and molasses (not sirup), 
brown bread and honey, stewed prunes, baked apples, figs, olive 
oil and olives, cod-liver oil, fresh green vegetables, orange juice, 
peaches, and whey. 

Foods Forbidden. — Certain foods should be absolutely forbidden 
to older children, such are cheese, dry fruits (except figs and prunes), 
fruits having small seeds, spices, pickles, nuts, raisins, dried, salted, 
or preserved foods of all kinds, canned corn, sweets, candies, cakes, 
and excess of farinaceous foods. All articles likely to produce flatu- 
lent dyspepsia must be avoided. Children on a mixed diet do well 
to avoid starchy foods and take more broths and soups. Variety 
in the diet is desirable. 

Children should be trained to go to stool at regular hours, and 
should be early taught the evil consequences of neglect to respond 
to the calls of Nature. School-teachers should not detain them at 



57$ DIET IN DISEASE 

their lessons when they are inclined to seek the closet. Water-closets 
or privies are often dark, cold, and otherwise disagreeable, so that 
children dread going to them. 

Abdominal massage is very helpful in overcoming chronic con- 
stipation in young children. It may be performed two or three 
times a day for five minutes. The movements should be made with 
the fingers of a warm, dry hand, which move the integument and 
abdominal wall over the intestine. The treatment must be very 
gentle, and if the muscular wall is tense, it may be conducted while 
the infant is nursing or feeding, as suggested by Fruitnight. 

Hemorrhoids 

Hemorrhoids usually complicate cirrhosis of the liver sooner or 
later, but they also result from chronic constipation and other causes. 
The dietetic treatment is substantially that of chronic constipation 
(p- 57 1 )- Much depends upon preventing the stools from becom- 
ing hard or bulky. Large quantities of coarse vegetables and cereals 
should therefore be avoided as well as milk. Alcohol is injurious, 
especially in the cirrhotic cases. Fresh fruits and abundant fluids 
are serviceable in uncomplicated cases. Regularity in meals and in 
time of going to stool should be enjoined, with abundant outdoor 
exercise. Straining at stool must be avoided. 

Appendicitis 

Causation. — Appendicitis is mainly interesting from the dietetic 
standpoint on account of the possible causative relation of certain 
food residues. In about one third of the cases fecal concretions are 
found in the appendix, and in one thirteenth foreign bodies have 
been discovered. It is a popular belief that the disease is often es- 
tablished by the presence in the intestine of grape seeds or skins, 
lemon, orange, or mustard seeds, cherry pits, bits of chicken bone or 
clam shell, etc., but such is not the case. Substances of this nature 
are no doubt often swallowed, but they seldom make their way to 
the appendix or do any harm ; and it is now known that the disease, 
while it may exceptionally be produced by such irritants, is com- 
monly caused in other ways, and is often of bacterial origin. I have 
known of one fatal case resulting from eating a large number of 
soft-shell crabs, but such accidents are very rare. On the other 
hand, both overeating and overdrinking may indirectly cause ap- 
pendicitis as well as the consumption of too highly seasoned foods, 
for these factors provoke catarrh of the intestine, distending the 
bowel with feces and gas, and making it easy for the catarrhal pro- 
cess or for bacteria of various sorts to enter the appendix and set 
up local inflammation there. The recurrent cases are more apt to 
be excited directly by overeating and improper food. 



THE ALIMENTARY CANAL 579 

Dietetic Treatment. — The dietetic treatment of appendicitis which 
has not yet passed into the surgeon's hands should consist in giving 
only such food as will be thoroughly absorbed, leaving as little 
residue as possible to irritate the lower bowel and excite peristalsis. 
Until the outcome of the attack is decided it is best to put the patient 
upon a fluid diet, consisting chiefly of nutritive broths. Beaten eggs 
may be allowed, and a moderate quantity of pancreatinised milk, 
whey, or buttermilk. Cocoa may be given, and strained gruels of 
rice or barley. 

In recurrent cases the patient should be cautioned to eat moder- 
ately and avoid all coarse or hard food, such as grits, coarse oatmeal, 
tough meats, fibrous vegetables, the skin of fruits or potatoes — in 
short, everything likely to overload the intestine with accumulated 
waste. 

The operative cases should have the diet recommended after 
laparotomy. Usually the digestive organs require almost absolute 
rest for twenty-four hours after the operation, and hot water may be 
sipped. No food at all should be given for fully six hours before 
operation. 

Acute Peritonitis 

Acute peritonitis, if due to causes within the alimentary canal, 
demands absolute rest of the stomach and intestines, and this is 
secured by giving all nourishment, stimulants, and medicines in 
the form of nutrient enemata (p. 408). Any food in the stomach 
is likely to excite vomiting and aggravate the pain and other symp- 
toms. 

Most cases of acute peritonitis demand laparotomy, and the die- 
tetic treatment is given under that heading. 

In other cases a very little fluid nourishment may be cautiously 
administered per os, such as peptonised milk, light gruels of pearl 
barley or arrowroot, plain meat juice squeezed from a fresh steak, or 
one of the forms of peptonised meat or Qgg albumin in sherry 
should be tried. Only one or two teaspoonfuls should be given once 
in fifteen minutes or half an hour, and every effort must be made 
to prevent the occurrence of vomiting or meteorism. Twelve or 
fifteen ounces per diem of predigested food given by the mouth 
is all that should be prescribed in such cases. The resumption 
of a full diet should be extremely gradual, occupying several 
weeks. 

It is well to avoid the use of aerated waters of all kinds on ac- 
count of their tendency to increase meteorism and render the patient 
still more uncomfortable. Alcoholic stimulation is usually required 
in severe cases, and if the stomach is intolerant it should be given 
in the form of dry champagne or dilute whisky or brandy. The 
latter mav be added to rectal enemata. 



580 DIET IN DISEASE 

The reader is referred to the section upon the diet for convales- 
cent typhoid-fever patients (p. 435) for hints as to selection of a 
menu for convalescents from peritonitis. 

Chronic Peritonitis 

In chronic peritonitis the outcome of chronic tuberculosis, or 
other disease, plainly cooked animal food agrees best. Starches 
and sugars, from their tendency to ferment and dilate the bowels 
with gas, should be avoided. Broiled tender chop, steak, chicken, 
or white meat of fish may be given. Eggs, milk, and cream are 
permitted when they do not cause dyspepsia. Bread should be eaten 
sparingly, and must always be stale or toasted. Zwieback and crack- 
ers are given for variety. All food should be eaten very slowly and 
in very moderate quantities at a time. 



DIET IN LIVER DISEASES IN GENERAL 

Biliousness 

Symptoms. — " Biliousness " is an unscientific but very convenient 
term employed to express functional disorder of the liver, usually 
accompanied by an oversecretion of bile, which is often vomited. 
The condition is characterised by headache, nausea, vomiting, con- 
stipation, a furred tongue, anorexia, offensive breath, malaise, and, 
if it continues, by a sallow, yellowish, or pasty complexion. 

Causation. — The most common cause of biliousness is eating too 
much food or too rich or badly cooked food combined with seden- 
tary habits. 

Sir Henry Thompson, speaking of the habit of overeating, says : 
" The surplus fund of nutrient material unused is stored up in some 
form. When a certain amount has been thus disposed of — the ca- 
pacity for storage varying greatly in different persons — an unde- 
sirable balance remains against the feeder, and in young people is, 
mostly rectified by a ' bilious attack.' This relieves the system for 
a month or six weeks, when the process may be repeated." 

" In functional derangements of the liver much more perma- 
nent benefit is to be expected from careful regulation of the ingesta 
than from physic " (Murchison). 

Continued disregard of the warnings of bilious attacks is liable 
to lead in time to more serious trouble, such as habitual lithsemia 
or oxaluria, and in some cases gout. It is possible, although it 
is not absolutely proved, that diabetes may be placed in the same 
category. 

Persons spending a holiday at the seaside, who breathe more 
invigorating air than that to which they are accustomed in inland 
cities, often are tempted to eat too much and exercise but little, 



LIVER DISEASES IN GENERAL 58 1 

with the prompt result of overloading the liver and inducing a bilious 
attack, for, as Harley says, the liver " acts like a wise horse when 
overloaded — simply stands still until part of its burden is removed." 

Those who have a tendency — often hereditary — to biliousness 
frequently exhibit idiosyncrasies in regard to special articles of diet, 
the eating of which, even in moderation, may quickly precipitate an 
attack. 

A bilious condition is sometimes induced by absorption of pto- 
maines from food in the alimentary canal, which are taken up in 
such quantity that the liver fails to destroy them. 

Bouchard has attempted to show that the ptomaine-destroying 
function of the liver is aided by glycogen, and is consequently 
favoured by ingestion of starches. 

Dietetic Treatment. — The digestive functions of the liver are so 
varied that it is difficult to arrange any diet for either functional or 
organic diseases of that organ which meets all the requirements of 
theory, but clinical experience has abundantly proved the value of 
certain general principles, the most essential of which is that the 
liver should be taxed as little as possible, and a non-stimulating 
diet is required. 

Food in general after it has reached the duodenum acts as a 
stimulant to the liver, and two or three hours after a full meal the 
bile secretion is increased ; but there are a few foods to which a 
special stimulating effect has been attributed, although their influ- 
ence, if any, is slight. These are chiefly the succulent vegetables, 
like tomatoes, and also spinach and cresses. Strong alcohol, condi- 
ments, such as pepper, mustard, spices, and especially curry, have 
the same effect, and should be avoided. Fats and sugars eaten too 
freely are very apt to disturb the action of the healthy liver, espe- 
cially during hot weather. 

Coffee and tea may be allowed only in such moderation as one 
cup a day. Alcohol had better be prohibited entirely. Beer, ale, 
porter, strong liquors, liqueurs, and all sweet wines, such as cham- 
pagne, sherry, Madeira, port, and Tokay, must be absolutely for- 
bidden. If necessary as a tonic, a little Rhine wine, hock, or Moselle 
may be used (not over a couple of glasses daily), or much-diluted 
whisky. Of all the organs of the body, none is more often poisoned 
and made cirrhotic by alcohol than the liver, and the moral needs 
no further emphasis. Many other chemical stimuli, such as opium, 
derange the liver functions and interfere with the elaboration of food. 

More or less intestinal dyspepsia always results from alterations 
in the quantity or composition of the bile, and on this account as 
well the food must be carefully selected, and all sugars and most 
starchy aliments must be forbidden as well as fats. 

Among the articles especially prohibited in all cases of liver 
disease are condiments, spices, curries, pickles, sauces, rich soups, 



582 DIET IN DISEASE 

fried food of every kind, veal, pork, sausages ; salt foods, such 
as corned beef and salt fish ; crustaceans, new bread, preserves, 
and sweets of all sorts ; pastry, puddings, cakes ; all the heavier 
starchy vegetables, such as potatoes, corn, peas, beans ; salad oil ; 
oily fish, like salmon and sardines. Only fresh food should be 
given. 

In acute functional derangement of the liver, whether there is 
imperfect or diminished secretion of bile or hypersecretion, it is best 
to considerably reduce all food in quantity. At first, if there are 
vomiting and headache, only light broths, beef tea, and perhaps dry 
toast or a cracker should be given. 

In acute hepatic disease the tongue becomes furred and the ap- 
petite is apt to fail. The latter, in a manner, keeps guard over the 
liver, for when that organ is overloaded or incapacitated to work a 
failing appetite leads to taking in less food until proper functional 
activity is restored. But there are many chronic cases in which con- 
tinued absence of appetite leads the patient to take less nourishment 
than is really needed, and in such cases it is not a reliable guide. It 
is not desirable to restrict the diet too closely or allow it to become 
monotonous. The palate should rather be tempted by reasonable 
variety. 

In regard to the suggestions given below, it must be remembered 
that they are very general, and are applicable rather to the chronic 
types of hepatic disease, although they will serve also for those 
afflicted with recurrent or intermittent attacks of biliousness, and 
should be followed between the attacks. In very active disease, 
such as acute congestion, acute yellow atrophy, abscess of the liver, 
etc., obviously the diet must be much more limited. In ordinary 
uncomplicated bilious attacks induced by high living, a day or two 
of practical starvation with the use of a mercurial cathartic is wholly 
curative. 

The following articles can usually be allowed in moderation ex- 
cepting in very severe cases : 

Animal Food. — Fish, such as sole, flounder, halibut, smelt, white- 
fish ; the soft part of oysters, liver, sweetbread ; lean meat, such as 
roast beef, broiled beefsteak, mutton chops, or chicken (lean beef 
is better than poultry or game) ; eggs, milk and its preparations, such 
as koumiss, whey, buttermilk, junket, malted milk. Many persons 
with hepatic disorder insist that milk always makes them bilious. 
If this proves to be true of natural milk, it should be predigested 
or given with sodium bicarbonate or Vichy, or in one of the numer- 
ous ways described on p. 78. 

In advanced cases of hepatic disease milk constitutes an excel- 
lent food, and may be used abundantly, provided the proper form 
for its administration in a given case is determined. Baked custard 
and blancmange or other forms of gelatin may be eaten. 



LIVER DISEASES IN GENERAL 583 

Vegetable Food. — Of fresh green vegetables the following may be 
eaten : Spinach, asparagus, tomato, squash, pumpkin, celery, oyster 
plant, beet tops, cresses, lettuce (without oil). 

Cereal Foods. — Bread should be eaten in small amount. It must 
be stale or toasted. Zwieback is good, and dry rusk, not too sweet. 
Graham, gluten, or wheaten crackers may be permitted. Other 
starchy foods should be eaten sparingly ; but boiled rice, rice pud- 
ding, sago, and tapioca are admissible. 

Fruits. — Fresh fruit in season is wholesome, and useful to over- 
come the tendency to constipation. Grapes, oranges, strawberries, 
peaches, and roast apples may be eaten. 

Water should be drunk freely, except when ascites is present; 
and light beverages, such as lime juice in aerated water, lemonade, 
or dilute raspberry vinegar, may be serviceable. 

Directions for Eating. — The manner of taking food is very im- 
portant. There is apt to be hyperemia of the stomach and intes- 
tines from time to time, as a result of engorgement of the portal 
system, and catarrhal conditions are easily excited in these organs 
by food which is hastily bolted without thorough mastication or 
which is not well cooked or not perfectly fresh. The teeth should 
always be examined to ascertain if the patient can masticate prop- 
erly. Fluids should not be drunk with meals. The patient should 
not eat directly after violent exercise or fatigue, but should first lie 
down and rest for three quarters of an hour. If he suffers from 
dyspepsia, he should rest after meals as well. In many cases three 
meals a day suffice, but they should be given at intervals of about 
six hours, to insure complete digestion between. In others, when 
considerably enfeebled, or in cases of hepatic congestion and ad- 
vanced cirrhosis, it is better to feed the patient four or five times a 
day, or once in three hours, giving a smaller quantity of food which 
is easily digested. It is advisable to take the principal meal at 
noon. 

From the fact that the bile is diminished in amount or altered in 
composition, constipation is the rule, and proper laxatives should be 
frequently given if the bowels cannot be kept in order by fresh 
fruit. 

Hot water in an empty stomach is quickly absorbed, and passes 
directly to the liver through the portal vessels. If salts, such as 
Carlsbad salt, are given, they are absorbed with the water, and 
stimulate the liver cells. The water increases the portal blood pres- 
sure, and thus indirectly the pressure of the gall ducts, and favours 
the elimination of bile. 

Moderate systematic exercise should be prescribed whenever 
possible, and the best forms are horseback and bicycle riding. The 
I jouncing " movements of the former shake and compress the liver, 
and stimulate its circulation and the outflow of bile. 
39 



584 diet in disease 

Acute Catarrhal Inflammation of the Gall Ducts — 
Angiocholitis — Catarrhal Jaundice 

A bland or non-stimulating diet must be given in the acute stage 
of angiocholitis. Vomiting is sometimes present, or it may be arti- 
ficially induced as part of the treatment, so that the stomach is not 
in a condition to bear solid food. Moreover, much food on entering 
the duodenum will increase the local inflammation of the common 
bile duct. Diluted or peptonised milk is to be given, or buttermilk, 
whey, light meat broths, clam broth, pressed-beef juice, tgg albumin. 

In a few days, if pain, tenderness, vomiting, and fever subside, the 
diet is to be slowly increased, and such articles may be added as milk 
toast, bread and milk, broths and light soups without vegetables, the 
breast of chicken, oysters, sweetbread, meat jellies. Later, eggs, and 
boiled or broiled fresh steak may be eaten. Fat and butter should 
be avoided, and pains should be taken to prevent constipation and 
putrescence of the intestinal contents. 

Fatty, amylaceous, and saccharine food is to be avoided, and 
for some time after the acute symptoms have subsided the basis of 
diet should be whitefish, lean meats, and fresh green vegetables. 

Cooked fruits, not too sweet, and to which sugar has not been 
added, such as sour apples, prunes, etc., can be eaten. Considerable 
fluid should be taken both as a diluent and to promote the action of 
the kidneys and lessen the tendency to constipation. Water acidu- 
lated with lemon juice or effervescent waters (soda water. Seltzer, 
and Apollinaris) may be drunk three or four times a day between 
meals. Coffee and tea are allowed only during convalescence. 

Cirrhosis — Ascites 

Causation. — Cirrhosis is a disease of the liver occasioned by 
irritation of that organ by substances in the blood derived more par- 
ticularly from the portal system after direct absorption from the 
intestine. Among those irritants may be mentioned as the foremost 
excitant alcohol, which produces fully 60 per cent of all cases. 
Strong alcoholic stimulants often contain fusel oil or other especially 
noxious impurities. The prolonged use of strong condiments, or 
spices, such as curry and peppers, may occasion cirrhosis, as also may 
chronic metallic poisoning by arsenic, antimony, lead, or phos- 
phorus. Experimentally, ptomaines have been made to excite the 
disease in the lower animals, and continued poisoning by such 
agents may possibly produce it in man. Cirrhosis may be caused 
in other ways, but the facts above mentioned show its frequent rela- 
tion to dietetic errors. As a result of fibrous hepatitis, the terminals 
of the portal vein are obstructed and the portal venous system is 
congested, the blood being dammed back in the vessels of the stom- 



LIVER DISEASES IN GENERAL 585 

ach, spleen, intestines, and pancreas. Owing to the congestion there 
is frequent vomiting, sometimes of blood, and there is marked inter- 
ference with the character of the digestive secretions as well as the 
process of intestinal absorption. 

Dietetic Treatment of Cirrhosis without Ascites. — Cirrhosis with- 
out accompanying ascites is often best treated by a milk diet for two 
or three weeks. Bread and crackers may be allowed with the milk, 
but nothing else. Hot water and aerated waters should be drunk 
in large quantities, fasting, to " flush " the liver. Subsequently a 
light diet is to be prescribed in accordance with the suggestions 
given for the treatment of liver diseases in general (p. 581). All 
condiments, relishes, sauces, fats, fried food, pastry, and sweets 
must be withheld, as well as alcohol in every form. The skin and 
bowels must be kept active. 

ASCITES 

Pathological Physiology. — A further important symptom which 
is seldom absent towards the close of a protracted cirrhosis, if the 
patient lives long enough, is ascites. This is an accumulation of 
serum in the peritoneal cavity, which has been produced by the 
altered blood pressure of the portal system and the altered compo- 
sition of the blood itself. The fluid accumulates with considerable 
rapidity, and may reach an enormous quantity — sometimes as much 
as twenty-four quarts — greatly distending the abdominal walls, float- 
ing the viscera out of position, and by pressure interfering with di- 
gestion and absorption. In addition the loss of so large a quantity 
of fluid from the blood is a serious detriment to nutrition, inasmuch 
as the ascitic fluid not only contains water in large amount, but 
scrum albumin, which may be present in the proportion of from I 
to 2 per cent to over 6 per cent. In the ascites accompanying 
cirrhosis the loss of albumin in this manner may be somewhat less 
than when the serous accumulation is due to other causes. 

These facts should be borne in mind in relation to the dietetic 
treatment of the disease. Repeated aspiration of the abdominal 
cavity not only abstracts large quantities of water from the system, 
but also abstracts considerable albuminous material. In those cases 
in which fluid refills the peritoneal cavity promptly after aspiration, 
it is a question whether the nutrition of the body may not suffer by 
drawing off so much serum albumin. On the other hand, when once 
transuded, it is of no further service to the organism unless it can be 
reabsorbed. The point for consideration is whether too frequent 
removal of the ascitic fluid will cause greater drain on the blood 
than would be consequent upon letting it accumulate in the abdom- 
inal cavity. Much will depend upon the relative pressure within the 
peritoneal sac and the blood vessels, which will affect the rate of 



586 DIET IN DISEASE 

osmosis of albumin. This discussion leads to the query, whether it 
is not necessary to supply the constant loss of albumin by an in- 
creased allowance of animal food, and, secondly, to what extent 
water should be withheld from the dietary. 

Dietetic Treatment of Cirrhosis with Ascites. — When uncompli- 
cated ascites is present it is generally best to restrict the quantity of 
fluid ingested and put the patient upon a " dry diet," consisting of 
bread and meat chiefly. By simply withholding fluid and stimu- 
lating the force of the heart and the action of the kidneys I have 
sometimes seen large quantities of fluids disappear from the abdom- 
inal cavity ; but this treatment is not always successful. There is 
more hope of success when the disease occurs in young persons, or, 
as it sometimes does, in children. Cirrhosis and ascites are very 
apt to be associated with renal and cardiac lesions and gastric ca- 
tarrh, which make it much easier to say what food the patient must 
not eat than what he can have. If the urine is very scanty it may 
not be wise to withhold fluids, and some clinicians of wide experi- 
ence believe in giving fluids in unrestricted amount, holding the view 
that this will increase diuresis to such an extent that not only will 
all the fluid drunk be promptly eliminated, but that the active kid- 
neys will drain more from the blood, which will in time be replaced 
by reabsorption of the ascitic fluid. The same reasoning is often 
applied to cases of pleurisy, general anasarca, etc. It seems much 
more rational to endeavour to promote diuresis when possible by 
medicinal measures than to add a large bulk of fluid to an already 
overbalanced circulation. 

It is of importance in every case to measure and estimate care- 
fully the total amount of fluid ingested both in beverages and as 
food and make a comparison with the quantity of urine voided, and 
if possible with the weight of the patient and girth of the abdomen 
at different levels. 

If the fluid diet is followed by rapid reaccumulation of ascitic 
fluid after aspiration, for example, within a fortnight, it is desirable 
to replace it by as much simple solid nutriment as the patient can 
digest, or by predigested and concentrated foods. An outline of the 
appropriate diet for such cases will be found upon p. 431. 

The " grape cure " and " milk cure " have been strongly recom- 
mended in Europe for the treatment of cirrhosis and ascites. They 
are said to ameliorate the symptoms and promote reparative pro- 
cesses, both acting largely through diuretic influence. 

Fatty Liver 

Pathological Physiology. — The liver is the great storehouse of 
latent energy in the body, which is accumulated in glycogen and 
fat. A certain proportion of fat is to be regarded as a normal con- 



LIVER DISEASES IN GENERAL 587 

stituent of the parenchyma of the liver. This varies considerably 
within normal limits, depending upon the character of the food in- 
gested and the degree of its oxidation in the liver and other tissues. 
After a diet consisting largely of fats and oils or of carbohydrates 
the accumulation of fat in the liver is considerable. Lack of exer- 
cise and unfavourable hygienic conditions, by retarding oxidation 
processes, also promote its accumulation. Persons addicted to con- 
stant overeating of carbohydrates are therefore liable to this affec- 
tion. They become stout, take less and less exercise, and the second 
condition favouring fatty infiltration of the liver — namely, lack of 
oxidation — is added. Fatty liver is also caused by various diseases 
in which the composition of the blood is altered and the metabolism 
of oxidation is interfered with. Such are advanced anaemia, chronic 
alcoholism, and tuberculosis. It is suggested by Fitz that the fatty 
diet often recommended for the latter disease — consisting of cod-liver 
oil, rich milk, butter, cream, etc. — is productive of fatty disease of 
the liver. 

Dietetic Treatment. — The dietetic treatment is indicated by the 
previous considerations, but since the local condition is commonly 
merely an accompaniment of more serious general disease, it may be 
unwise to advise too sudden or extreme alterations in the accustomed 
diet of the patient. In general, all forms of sugar, starch, and fat 
should be reduced gradually to a minimum, and, if possible, finally 
omitted entirely, excepting in tuberculous patients whose general 
bodily nutrition is of more importance than the danger of local fatty 
infiltration. In these cases the object desired is better promoted by 
increasing oxidation processes by climatic and hygienic treatment 
rather than by withholding the carbohydrates. Malt liquors and 
alcoholic drinks in general must be forbidden. In other cases, espe- 
cially in the alcoholic form, the diet should consist of nitrogenous 
food, fresh green vegetables, and fresh succulent fruits. The fol- 
lowing articles may be taken : Lean meat, boiled or broiled fresh 
fish, lettuce, spinach, celery, tomatoes, gluten bread, and toast. 

Amyloid Liver 

The condition of amyloid liver after it has become sufficiently 
pronounced for diagnosis is usually fatal within a short period, and 
consequently but little aid can be derived from dietetic treatment. 
The diet should be so regulated as to burden the digestive organs as 
little as possible, and in advanced cases such predigested foods as 
peptonised meat or milk ought to be given. If the stomach diges- 
tion is fairly active, nitrogenous food will agree better than the 
carbohydrates. 



588 diet in disease 

Syphilis of the Liver 

In advanced syphilitic hepatic disease non-stimulating food only 
is permissible, such, for example, as milk and eggs, chicken, beef 
or mutton broths, fresh fish, oatmeal, boiled rice, semolina, reva- 
lenta, bread, and light farinaceous puddings — such as tapioca, sago, 
blancmange, and custards. Alcohol in all forms is prohibited. 

Abscess of the Liver 

In hepatic abscess the same general dietetic treatment is to be 
followed as that indicated for syphilitic disease of the liver. The 
aim should be to carefully avoid overloading the digestive organs at 
any time, and to give assimilable and predigested food in small 
quantities at frequent intervals, at least once in three hours. Animal 
broths and light vegetable purees, with various combinations of milk 
and eggs, should form the staple articles. No solid foods should be 
given, excepting such as a little fish, such as sole or haddock, a few 
oysters, sweetbread, and milk toast. 

Fats in all forms are forbidden. Malt liquors, port, sherry, and 
all forms of strong alcohol must be prohibited. If any stimulant is 
required, a little hock, Moselle, or champagne may be taken, or very 
weak brandy, diluted with Apollinaris or Vichy. 

Gallstones 

Pathological Physiology. — Gallstones are formed in the gall 
bladder or larger bile ducts by precipitation from the bile of choles- 
terin, mixed with more or less mucus. Occasionally they contain 
the bile pigment (bilirubin) or calcium carbonate. Cholesterin is an 
alcoholic substance which may be extracted in varying amount from 
the blood or nervous tissues, especially the brain, and from the bile. 
It may be obtained in flat, rhombic, colourless crystals. Somewhat 
rarely it is excreted in the urine. It also exists in the waste matter 
contained in the lower bowel. Cholesterin is maintained in solution 
in the bile by alkaline salts, the sodium and potassium taurocholate 
and glycocholate. Calcium unites with the latter substances, form- 
ing new compounds with the biliary acids which are insoluble salts 
that no longer keep cholesterin in solution. When organic acids 
exist in excess in the tissues calcium is liberated, and on reaching 
the liver produces the above reaction. 

An excessive accumulation of cholesterin in the system will re- 
sult in its precipitation from the bile, and this occurs when for any 
reason the bile has long been retained in the gall bladder, where it 
has been concentrated by reabsorption of some of its fluid ingre- 
dients. Bacteria are undoubted agents in the formation of many 



LIVER DISEASES IN GENERAL 589 

stones. The precipitation of cholesterin is favoured by the presence 
of a pre-existing hepatic stone or any foreign body in the gall blad- 
der, such as an intestinal parasite, or its ovum, or thickened mucus. 

Gallstones are oftenest present in advanced life and among those 
who adopt sedentary habits which lead to accumulation of bile in the 
bladder. On the latter account they are more common among 
females, and their occurrence is often related to excesses of the table, 
in regard to both food and drink. 

All diseases of nutrition, such as long-continued dyspepsia, 
chronic rheumatism and gout, diabetes, and obesity, may be accom- 
panied by the formation of biliary calculi. 

Among other explanations given for the formation of gallstones 
is an excessive proportion of fat in the diet, although cholesterin is 
not true fat, but is really an alcohol allied to fats in some of its 
properties. Lack of exercise is a contributing factor. 

Harley, who has given more careful attention than any other 
writer to the prevention of a return of gallstones by dietetic treat- 
ment, called attention to their greater prevalence in cold latitudes 
than elsewhere, and attributed this fact to the influence of certain 
foods, especially meat fat and suet. He wrote : " Starchy puddings 
and fat bacon cause more gallstones in this country [England], I 
believe, than all the other kinds of food put together." 

The hydrocarbons are more completely consumed in early years 
than after middle life, and hence the greater prevalence of gallstones 
in the latter period, as above mentioned. 

Bauer believes that " the formation of gallstones may often be 
referred to a faulty diet, for an excessive consumption of meat or 
free indulgence in fat and in spirits would probably favour their 
formation." 

Less often gallstones are composed of pigment or of calcium 
carbonate, or of various mixtures of these substances with one an- 
other or with mucus. Individual stones sometimes attain the size 
of a small Qgg, and they may cause suppuration and the formation 
of a fistula from the gall bladder which opens into some other ab- 
dominal organ, or externally. 

In many cases the stones exist in considerable number and size 
without giving rise to any symptoms or discomfort, but the smaller- 
sized stones occasionally find their way into the common bile duct, 
and their passage provokes intense agonising local pain, known as 
biliary colic. 

Dietetic Treatment. — From the above account of the manner of 
formation of bile stones it is evident that patients who have once 
suffered from biliary colic or other symptoms of the presence of 
concretions should exercise care in their diet and habits of life, in 
order to prevent the further formation of stones, and, if possible, to 
aid in dissolving those already present. The diet must be regulated 



590 DIET IN DISEASE 

with the object of lessening the production of cholesterin and of 
diluting the bile. Animal food may in itself contain cholesterin, and 
should therefore be taken very sparingly. A diet of concentrated 
animal food, by diminishing the alkalinity of the fluids of the body, 
favours the deposition of cholesterin from the bile, although this 
ingredient may not be present in abnormal amount in such food. 
Patients should be cautioned against excessive indulgence in any 
particular article of food, all richly cooked food must be given up, 
and if they are in the habit of eating nitrogenous food in excess, a 
larger proportion of fresh vegetables or farinaceous food should be 
substituted. 

Calves' brains and the viscera of animals used as food in general, 
and particularly the liver, should be wholly interdicted. Sugars and 
fats must be forbidden in every variety. 

Some vegetables, such as peas and carrots, are believed to con- 
tain material which closely resembles cholesterin. Carrots, more- 
over, are sweet, and sweet vegetables and fruits should be avoided, 
and also egg yolks, on account of the fat they contain. 

Fresh green vegetables and acid fruits which, by virtue of their 
alkaline salts and organic acids, easily combine in the blood with 
alkaline bases should make the basis of the diet. The potassium 
salts which are contained in potatoes and other vegetables in abun- 
dant quantity are believed to be serviceable, because they retard the 
liberation of calcium, which, it has been shown, precipitates choles- 
terin. Bread and well-cooked cereals and fresh fish, except salmon 
and mackerel, may be eaten. Chicken or lean beef may be allowed, 
but all meat should be taken sparingly and not oftener than once 
a day. 

For the purpose of diluting the blood and, through it, the bile, 
large quantities of fluid should be ingested, but it is best to avoid 
aerated waters and mineral waters which contain salts of lime. A 
tumblerful of hot water should be drunk at night, and another on 
rising in the morning. Champagne and other beverages which hold 
much carbonic-acid gas in solution must be avoided, as must malt 
liquors. Coffee, tea, and claret may be drunk in moderation. If 
the case is one in which considerable gastric catarrh or dilatation of 
the stomach is present, it is inadvisable to give much fluid by the 
mouth, and sometimes the desired result may be obtained by inject- 
ing salt water through a long flexible rubber tube into the colon. 
Intestinal irrigation as well as active purgation favours removal 
of the bile and prevents its accumulation in the gall bladder. Prout 
gives one or two drachms of sodium phosphate or sulphate daily 
to prevent concentration of the bile. For purgation the Carlsbad 
Sprudel salts and Saratoga salts are valuable. In women tight 
lacing should be prevented, and the habit of sitting long in cramped 
positions which interfere with free hepatic circulation. 



THE NERVOUS SYSTEM 591 

Large doses of olive oil, several ounces at a time, have been 
recommended for use during the passage of a gallstone, with the 
idea apparently of in some mysterious way lubricating the channels 
through which the stone is carried. But the oil, if absorbed, is taken 
up by the lacteals and emptied into the thoracic duct without going 
anywhere near the liver or bile passages, so that such an explana- 
tion of its use is absurd. The foreign bodies which it is claimed 
appear in the stools after giving oil in this manner have proved to 
be not stones, but inspissated masses of oil. 

PANCREATIC DISEASES 

Disease of the pancreas is usually impossible to diagnosticate 
with accuracy until it is far advanced, and but little can be ex- 
pected from dietetic treatment. Since the pancreatic juice is on 
every account the most important of all the digestive fluids, being a 
universal digestive agent for all foods, and the most vigorous one, 
its absence or deterioration results promptly in emaciation, which 
becomes extreme. When the presence of disease of this gland, such 
as a cyst, is established, it is best to withhold all fats and carbo- 
hydrates from the diet. They are not digested in the stomach, and 
when the pancreatic juice fails, they merely ferment in the small 
intestine and do positive harm. Milk, pancreatinised meat prepara- 
tions, beef peptonoids, and tgg albumin, with alcoholic stimulants, 
must constitute the chief reliance for nourishment. 

It is of interest to note that the continued presence of fat or oil 
in the stools is regarded as a strong diagnostic point in favour of the 
absence of pancreatic fluid. As a positive test this may have some 
value, but not as a negative one, for if bile is present in normal 
quantity the fat of food may still be emulsified and, to some extent, 
absorbed. In a half dozen cases of undoubted pancreatic cyst in 
which the diagnosis was established by aspiration or autopsy, I have 
known doses of several ounces of olive oil administered for diagnos- 
tic purpose to give no residue in the stools. The absence of fat in 
the feces does not therefore necessarily exclude pancreatic disease. 



DIET IN DISEASES OF THE NERVOUS SYSTEM 

Neuralgia — Gastralgia — Enteralgia 

Causation. — Neuralgia is a term applied to a variety of nerve 
pains which may be associated with organic lesions of various struc- 
tures which irritate the peripheral nerves, or which may be purely 
functional and temporary excitations of the nerve trunks or their 
end organs. Lesions involving the nerves themselves are not de- 
scribed as neuralgias. The irritability and conductivity of nerve 
fibres is so dependent upon nutrition that debility resulting from 



592 DIET IN DISEASE 

imprudent living and improper or insufficient food would naturally 
be expected to rank among the chief predisposing causes of this 
affection. 

Persons undergoing severe mental worry or strain, physical 
fatigue, prolonged exposure to cold, prolonged lactation, etc., are apt 
to suffer from indigestion or malassimilation of their food, and the 
one condition reacts upon the other in altering the tone of the 
nervous system. 

Moreover, many diseases which may be called dietetic in that 
they are so closely associated with or influenced by dietetic errors 
(acting eventually through the composition of the blood) are very 
commonly accompanied by neuralgic pains. Such are gout, rheu- 
matism, lithaemia, arthritis deformans, diabetes, and chronic alco- 
holism. To benefit the diseased condition by appropriate diet, 
among other means, is to cure the neuralgia. 

Neuralgic pains are often connected immediately with the digest- 
ive tract, especially in cases of neurasthenia and hysteria among 
women, and are excited by irritating foods or by fermentative pro- 
cesses. 

Dietetic Treatment. — The dietetic treatment of neuralgia is 
based upon certain general principles which may be observed where- 
ever they do not conflict with the special disease of which the pain 
may be merely an incidental symptom. This treatment is liable to 
be overlooked while attention is wholly given to devising new reme- 
dies for the immediate, though often merely temporary, relief of 
the pain. 

It is of the utmost importance to early ascertain the cause of 
the pain and learn whether it be not due to one of the conditions 
above mentioned, which may be found to exist in a latent form. 
Careful examination of the urine should in all cases be made to 
ascertain the possible presence of the uric-acid diathesis, of sugar, of 
phosphaturia, etc. 

Since a majority of cases are accompanied by general debility 
and occur in anaemic, constipated women who take little outdoor 
exercise, the blood also should be examined for anaemia. A nutri- 
tious and ample diet should then be prescribed, accompanied by 
moderate exercise and abundant fresh air, to insure more perfect 
oxidation. Anstie says correctly that " neuralgic patients require, 
and greatly benefit by, a nutrition considerably richer than that which 
is needed by healthy persons." This is particularly true of the ex- 
tremes of age. 

Fats and oils are most serviceable, and under this heading cream, 
Devonshire cream, butter, bacon, fat meat, salad oil, olives, and cod- 
liver oil may be used. 

Neuralgic patients usually dislike fats, perhaps on the general 
principle that people are likely to prefer different food from that 



THE NERVOUS SYSTEM 593 

which they most need for disordered conditions of the system. 
Some are even made bilious by fat, but with a little tact and perse- 
verance in selecting the proper kind of fatty food and directing the 
mode of taking it these objections may be overcome. Patients may 
take more butter than usual, though they refuse cream, or they will 
take cream though they refuse cod-liver oil. Salad oil and fat bacon 
are not apt to provoke objection. 

In neuralgia due to general debility or anaemia without lithiasis, 
nitrogenous foods are indicated in addition to the fats above men- 
tioned, and good roast beef, beefsteak or chops, eggs, milk with 
bread and butter, light starchy foods, and fresh vegetables should be 
ordered. Meat should be eaten two or even three times a day, and 
additional lunches may be given between meals, consisting of milk, 
a glass of claret and a sandwich, a cup of cocoa and a biscuit, or 
broth thickened with beef meal or an egg. 

Gowers says that he has sometimes known " severe neuralgia to 
occur first on the patient commencing a purely vegetable diet, to 
disappear when meat was taken, and recur with severity on each of 
four successive attempts to return to vegetarianism." 

If the nervous system has been greatly overtaxed or the digest- 
ive organs are exceptionally feeble, it may be advisable to put the 
patient for a few days on a diet consisting largely of milk, eggnog. 
beef broth, and purees, accompanied by rest and passive exercise 
(massage). After a few days the more substantial nitrogenous foods 
may be added. In cases associated with lithaemia or rheumatic 
diathesis, however, the quantity of such foods should be reduced, 
and the special regulations described under the heading of rheuma- 
tism and lithaemia must be followed. 

Coffee and tea should be used only in moderation, and in bad 
cases had better be prohibited altogether. 

Alcohol in restricted dosage benefits many anaemic cases. Claret 
or Burgundy may be drunk with meals, but alcohol should never be 
taken merely to relieve pain or otherwise than a food, for there is 
danger of becoming too much addicted to its use. 

Substances to be especially forbidden are pastry, sweets, and 
confectionery of all kinds, griddle cakes, condiments, fried food, 
and rich, highly seasoned sauces and foods. 

All meats should be eaten at regular intervals, and, except as 
directed above, eating between meals must be prohibited. 

VISCERAL NEURALGIAS 

The visceral neuralgias are produced in the sympathetic nerves 
chiefly. The digestive viscera — stomach, intestines, liver, etc. — in a 
normal state are free from sensory impressions, but their nerves are 
constantly conveying reflex impressions, which, however, are to be 



594 DIET IN DISEASE 

distinguished from ordinary tactile sensibility. Hypochondriasis, by 
concentrating mental attention upon the various abdominal viscera, 
undoubtedly develops hypersensitiveness to such nerve currents. 

The condition described as ptomaine poisoning and various 
forms of auto-intoxication may excite a severe neuralgia as a 
symptom. 

Dietetic Treatment of Visceral Neuralgias. — Neuralgias of any of 
the abdominal viscera are apt to be excited by functional activity 
(although they also may occur independently of it), and hence the 
diet should be made as simple and nutritious as possible, in order 
that digestion shall not be unduly prolonged. If any one article of 
food is found to excite the paroxysms it should be abandoned. It 
is often advisable in severe cases to limit the diet for a few weeks 
to two or three simple articles of food, such as beef, bread, milk, 
and rice. 

GASTRALGIA 

Causation. — In neuralgia of the stomach, called gastralgia, or 
gastrodynia, the pain is situated in the epigastrium, penetrating to 
the back. It is distinctly localised and intense. It may be par- 
oxysmal, or there may be dull constant aching with exacerbations 
of a moderate lancinating character. It is usually relieved some- 
what by moderate gentle pressure, but intensified by deep pressure. 
Such pain is not infrequently associated with anaemia, chronic con- 
stipation and hysteria, and in a severe form, accompanied by violent 
vomiting, it constitutes the " gastric crisis " of locomotor ataxia. 
Gastralgia may also be occasioned by the continued excessive use of 
stimulants, such as alcohol, strong tea and coffee, and chewing 
tobacco, and by the inordinate use of sweets. An excessive forma- 
tion of hydrochloric acid in the gastric juice may occasion a very 
painful variety of gastralgia. 

Dietetic Treatment. — In all cases of gastralgia careful inquiry 
must be made in regard to irregularities of diet, and the relation be- 
tween eating and the occurrence of the pain. If the pain is worse 
while the stomach is empty and is mitigated by taking food, it is 
suggested by Gowers that it is due to morbid action of those nerves 
which normally excite hunger. Such cases should be treated by 
giving nourishment in frequent small quantities. In addition to the 
three regular meals of the day, which should be light, a glass of 
wine or a cup of hot bouillon and a biscuit or two, or a glass of 
milk punch or eggnog, may be taken at n a. m., 4 p. m., and again 
before retiring. A tumbler of milk or a few crackers may be kept 
by the bedside and taken in the middle of the night should the pa- 
tient be awakened by the pain. The pain itself is an indication of 
impoverished nutrition, and the nervous system requires rest while 
the tissues need food. In still other cases food intensifies the pain 



THE NERVOUS SYSTEM 595 

and excites immediate emesis. This is especially true of the gastric 
crises of locomotor ataxia. Here sedatives, such as bismuth, cocaine, 
or anodynes must be given to relieve the irritation of the gastric 
mucous membrane while food is temporarily withheld until the pain 
has subsided. The diet subsequently should be gradually increased, 
commencing with small quantities of peptonised albuminous food. 
In gastralgia the appetite is very capricious, and there may be ex- 
cessive craving for certain articles of diet, such as pickles, condi- 
ments, etc. 

In all forms of gastralgia the pain is aggravated by distention of 
the stomach. If starchy food tends to produce flatulency it should be 
avoided, together with sugars and fats. Tea and coffee and tobacco 
must be given up. The bowels should be kept freely open. 

Enteralgia — i. e., a true neuralgic pain in the intestines — is not 
common if " peristaltic unrest " be excluded. It does occur, how- 
ever, and most frequently in the lower rectum, in which case it is to 
be relieved by local treatment rather than dieting. 

Hepatalgia, or neuralgia of the liver, is an indication of func- 
tional overwork of that organ, which may be relieved by a careful 
inquiry into the dietetic habits of the individual and correction of 
errors in addition to purgation. 

In severe forms of neuralgia which do not yield to dietetic and 
medicinal control prompt relief is often secured by change of scene 
and sea bathing, or a course of mineral baths. Hygienic measures 
improve functional activity and promote oxidation and assimilation 
by the tissues of the products of digestion, as well as the elimination 
of waste. 

Migraine 

Migraine, or " sick headache," is a neurosis characterised by pain 
in the course of the fifth nerve, often accompanied by nausea, vomit- 
ing, mental depression, and local vasomotor disorders. 

There are many causes assigned to this affection, among them 
heredity, the gouty diathesis, improper food, etc. Some obstinate 
cases are unaffected by diet, but others are much benefited by atten- 
tion to it. and it is always worth while to attempt a cure by it. The 
patient should be very closely interrogated in regard to all the habits 
of diet and hygiene, such as the hours for eating, the kind of food 
eaten, its method of cooking, bathing, exercise, mental work, hours 
and frequency of the stools, etc. In this way only can possible faults 
be detected and corrected. The gouty should be forbidden the use 
of wines, malt liquors, sugars, and starches. The anaemic should be 
ordered more animal food and fats and cod-liver oil. The dyspeptic 
should abstain from carbohydrates. The neurotic should give up 
tea, coffee, and tobacco. It has been shown by Roberts that both 
tea and, to a lesser extent, coffee may materially retard starch diges- 



596 DIET IN DISEASE 

tion, even when drunk in very small quantities. Yet there are some 
patients who can ward off an impending attack of migraine by taking 
two or three cups of strong tea or black coffee. 

Plain cereal foods may be allowed, such as wheaten grits, " ger- 
mea," hominy, and oatmeal, but the addition of milk and sugar to 
them may cause fermentation and make them undesirable. In this 
case saccharin may be substituted, or an extract of malt. 

Fresh green vegetables, such as asparagus, young peas, French 
beans, string beans, sea-kale, and stewed celery may be eaten, but 
potatoes, corn, cabbage, tomatoes and rhubarb should be avoided. 

Excepting anaemic patients, those suffering from migraine should 
not eat much meat. It is best to take it not oftener than once a day, 
and the white meat of poultry and broiled fresh fish are better than 
much red meat. 

Milk may disagree and cause headache through lactic-acid fer- 
mentation, interfering with digestion. 

New bread, pastry, richly cooked food, condiments in excess, 
shellfish, crustaceans, cheese, sauces, and desserts in general are for- 
bidden. Many of these foods may produce ptomaines by putrefac- 
tive fermentation, which act as poisons to the blood and nerves. 
Vinegar and acid fruits should not be eaten, especially in connection 
with amylaceous foods (Roberts). 

Obviously no rules of diet apply to all cases of a disease which 
may originate from so many different causes, and in chronic cases 
careful observation and experimentation will be necessary to estab- 
lish the best course. 

Overeating, irregular eating, and late suppers should be forbid- 
den. Outdoor exercise, bicycling, or horseback riding should be 
prescribed to aid digestion, and the bowels should be kept active by 
eating fruits. 

Patients are often found who, as a result of following every one's 
advice, have gradually cut down their diet, one article at a time, 
until they are actually suffering from inanition, and it requires no 
little tact and firmness to convince them that they can eat anything 
at all. They will live on nuts and fruit alone, or on hot water and, 
raw beef, or follow the latest dietetic " fad," whereas they really need 
a common-sense diet of plain, nutritious food, such as that prescribed 
above for neuralgia or anaemia. 

Decayed teeth are a frequent cause of facial or other neuralgias, 
and the pain is often directly excited through the food or liquid 
taken being too hot or too cold, or strongly sweet or sour. Many 
persons experience temporary but severe frontal pain after swallow- 
ing iced beverages or ice cream too rapidly. In some persons the 
site of the pain is in the vault of the pharynx or in the throat itself. 
It is often relieved by momentarily compressing both carotid arter- 
ies. Brunton suggests that cold excites the sympathetic plexuses 



THE NERVOUS SYSTEM 597 

about the carotids and alters their calibre, putting them into a state 
of spasm. These forms of neuralgic pain are, however, usually triv- 
ial, and are to be avoided by proper care of the teeth and regulating 
the temperature of the food. 

Neurasthenia 

Causation. — Neurasthenia is a condition of loss of tone of the 
nervous system which is of a functional rather than an organic char- 
acter. It is also called nervous exhaustion or nervous prostration. 
Strictly speaking, it is not a disease, but rather a functional derange- 
ment of considerable duration, which, however, with proper care and 
dietetic treatment results usually in complete recovery. The most 
apparent cause of neurasthenia is overwork of the nervous system 
due to continued excitement or strain or prolonged emotional de- 
pression and anxiety. It is far more apt to be produced by overwork 
of the nervous system than of the muscular system, although it may 
be occasioned by the latter. Different individuals are endowed with 
varying degrees of nerve force, and the complex demands and great 
activity of highly developed civilisation tempt or compel many peo- 
ple to draw upon their physiological capital of energy at the expense 
of its income, with the result of exciting the entire central nervous 
system, including both brain and spinal cord, to an unwonted and 
sometimes dangerous degree. For this reason neurasthenia is 
essentially an affection incident to the occupations and customs of 
city life, rare or comparatively unknown in the repose of the coun- 
try. It is a curious but undeniable fact that there appears to be 
more or less fashion in regard to some diagnoses, in nomenclature at 
least, if not in the diseases themselves, and of late years " nervous 
prostration " has taken rank among ordinary functional disorders. 

The general name neurasthenia includes a large variety of nerv- 
ous symptoms, and while all of the physiological processes of the 
body are more or less impaired, the symptoms may predominate in 
one or more mechanisms, as, for instance, that of the circulation, 
gland secretion, or absorption. 

Men who find themselves in business straits or in circumstances 
of prolonged anxiety feel that they are straining their vital powers, 
and resort to an increased or excessive use of stimulants, such as 
alcohol, tobacco, coffee, and various drugs, to excite their overtaxed 
mental and physical powers into greater activity. By means of this 
substitution of force, especially with the use of alcohol, they are en- 
abled to work on, and still further excite a debilitated nervous system 
until finally the limit of endurance is reached, and some slight addi- 
tional strain reduces them to utter prostration. Not infrequently 
local functional disorders, such as writer's cramp, neuralgia, etc., give 
warning that a general neurasthenic condition is imminent, and if 



598 DIET IN DISEASE 

this warning be not heeded in time, more serious symptoms inevi- 
tably follow. 

Neurasthenia reacts on the digestive system, producing malnutri- 
tion and a variety of functional disorders, for so dependent is the 
whole alimentary canal upon a normal vigorous blood supply and 
nerve regulation that it necessarily suffers profoundly. 

General Treatment. — The treatment of neurasthenia is funda- 
mentally based upon two absolutely essential conditions: First, 
complete body rest, with the necessary absence of the original ex- 
citing cause of the difficulty, which will enable the impoverished 
tissues to become regenerated and have the balance of their energy 
properly retarded ; secondly, a nourishing diet, which will supply 
the material for this energy and tissue metamorphosis. Various 
tonics, such as strychnine, iron, and arsenic, are of recognised bene- 
fit to the nervous system, but the main reliance in all treatment 
must be placed upon rest and food. The milder cases may be re- 
lieved by a change of occupation and the enforcing of strict rules 
in regard to the hours of sleep, the methods and time of eating and 
taking exercise, bathing, etc. Many persons with functional nervous 
disorder have no appetite early in the day, but towards evening can 
eat a substantial meal, and they should dine late. 

Patients who for years have been accustomed to exceedingly 
active mental work find it almost impossible to endure confinement, 
absence from social intercourse, and lack of occupation, and in such 
cases the advantages of dietetic treatment may be enhanced by cheer- 
ful surroundings and diversion. As a rule, it is far easier for the 
fatigued or worried business man or " brain worker " to break off 
completely his accustomed occupation for a period of several weeks 
or months, to be spent in travel or at some foreign spa, than it is 
for him to continue his ordinary occupations in moderation, and take 
exercise and proper food and sleep in accordance with the rules laid 
down by the physician. 

In many cases of this nature travel affords a certain and fairly 
prompt relief, but it has the disadvantage that it involves consid- 
erable irregularity in the hours of rest, character of diet, etc., as well 
as the fact that many are deterred from this means of cure by the 
expense involved. In another class of cases too active travelling 
is stimulating and fatiguing, and if such people are not made ill 
at sea nothing gives more benefit than the isolation, invigorating 
air, and enforced idleness of a sea voyage. For others, in whom 
the digestive system is comparatively little impaired, camping or 
living an outdoor life in the woods affords the same advantage. 
Whatever journey is undertaken, therefore, should be in the direc- 
tion of rest and moderate diversion without the sight-seeing which 
is involved in visiting new cities. The physician should not only 
study carefully the previous habits of the patient, but should con- 



THE NERVOUS SYSTEM 599 

suit his tastes in regard to occupations and amusements. When 
this is done and his confidence has been thoroughly gained, it is 
far easier to have the rules for diet which are prescribed carefully 
adhered to. In still another class of cases of neurasthenia the gen- 
eral nerve breakdown is so sudden and the exhaustion so ex- 
treme that absolute rest at home and in bed is imperative. To 
this class of cases belong a large number of overworked society 
women whose lives of constant excitement and mental activity or 
stimulation, combined with the number of charitable interests or 
other occupations to which they give much energy, wear them out 
in time. 

The most severe cases of neurasthenia require special treatment, 
the principles of which are, first, complete rest for body and mind ; 
secondly, systematic feeding; and thirdly, massage. This treatment 
is applicable to those cases in which the nervous system is so 
greatly exhausted that the patient suffers continual depression from 
the least exercise, exertion, or emotional excitement. In some in- 
stances insomnia is a predominant and serious symptom ; in others 
the patient is drowsy in the daytime and unable to perform any 
concentrated mental labour ; in others again inanition is the most 
pronounced feature, and the rapid loss of weight and failure of 
strength alarms the patient, or the body may even increase in weight, 
while the muscles become soft and so feeble as scarcely to support 
the frame. Many cases are complicated with pronounced hysteria, 
hypochondriasis, or unnatural irritability. 

One of the first requisites in treatment is to secure a faithful 
and intelligent nurse and to isolate the patient from well-meaning 
but oversympathetic friends whose constant inquiries and sugges- 
tions are apt to aggravate existing conditions by focusing the 
attention of the patient upon them. In general, it is best to allow 
no one to see the patient excepting the trained nurse, the physician, 
and perhaps some one trusted member of the family. All business 
matters and domestic news of an exciting or depressing character 
should be carefully kept from the patient, and such connection as 
may be allowed with the outside world should be only of a cheer- 
ing and encouraging nature. 

It is very important that the nurse, who is so constantly with the 
patient, should be congenial and possessed of the requisite tact and 
cheerfulness of disposition. Many of these details may seem 
trivial, but their importance is appreciated after experience, which 
shows how easily infringement of the rules, such as the untimely 
reception of exciting news or the visit of an untactful friend, may 
react upon the digestive system and interrupt the favourable prog- 
ress of the case for several days. This is particularly true of all 
hysterical cases. On the other hand, there are some instances in 
which patients with active minds do decidedly better if mild, pleasur- 
40 



600 DIET IN DISEASE 

able occupation or entertainment, such as reading aloud, is provided 1 
for them, which is carefully limited to prevent fatigue. 

It is necessary to explain the general plan of cure and its 
object to both patient and family in order to secure their coopera- 
tion, and this having been done, the treatment which has received 
the name of " rest cure " should be outlined by definite rules in a 
most careful and systematic manner. To be of any service, the rest 
cure should last six weeks or more, and in severe cases it should be 
explained that this treatment by no means completes the restora- 
tion of the normal nerve functions, but is to be regarded as a basis 
for a further regimen of exercise and outdoor life. While the rules 
for diet for individual cases must be distinctly laid down, and con- 
scientiously adhered to, there is scarcely any other variety of disease 
in which the physician is called upon to exercise more tact and dis- 
cretion, and the success of the treatment will depend very largely 
upon the extent to which he adapts its provisions to the needs of in- 
dividual cases. It is comparatively easy to prescribe definite regula- 
tions for the treatment of neurasthenia, but practically there is no 
case which does not present individual peculiarities which require 
special consideration. 

THE "REST CURE" 

At the commencement of treatment in severe cases the patient 
must lie absolutely quiet in bed and not be even allowed to raise 
the arms or head to take food. After a week or ten days of such 
enforced and absolute rest, the patient may gradually be allowed to 
sit up and feed herself, but usually a full month or six weeks should 
be spent in bed with no further exertion. The lack of voluntary 
exercise must be supplied by the tonic effect of bathing and mas- 
sage. The patient should receive a sponge bath every morning soon 
after breakfast, which is to be given with hot water, or hot sea 
water if it can be obtained. A portion of the body only is to be 
sponged at a time, and friction with a coarse towel should immedi- 
ately follow. In some cases benefit results from rubbing a piece of 
ice or a cloth dipped in ice water over the skin for a moment after 
the hot-water sponging. The alternate stimulation of the cutane- 
ous nerves by strong degrees of heat and cold always produces a 
tonic effect, and the influence of the ice water and friction is analo- 
gous to that produced by the Brand system of cold bathing. 

After the bath, which, if properly given, may consume a half or 
three quarters of an hour, the patient must be allowed to rest, and 
at noon or in the early afternoon massage is to be given, at first 
every day, and later on alternate days. At the commencement of the 
case the massage should be exceedingly mild, and caution is required 
in this respect, for neurasthenic patients are often injured by the 
too vigorous or prolonged efforts of the massage operators. For 



THE NERVOUS SYSTEM 6oi 

the first day ten or fifteen minutes will suffice, and if the effect is 
favourable, the time may be gradually extended to an hour. Owing 
to the nature of the diet, which at first is of milk, and from the 
lack of exercise and loss of tone of the intestinal walls, neurasthenic 
subjects are uniformly constipated, and the massage should be par- 
ticularly adapted to remedy this difficulty. 

Massage of the abdominal muscles should be performed by 
gently rubbing and kneading the abdomen, commencing in the right 
iliac fossa and following the direction of the colon upward to the 
free border of the ribs across to the opposite side and downward 
to the sigmoid flexure. By this means peristaltic action is undoubt- 
edly stimulated, and the contents of the large intestine are mechan- 
ically propelled in the proper direction. 

Dietetic Treatment. — The feeding of the patient must be based, 
upon the principle of giving all the nourishment which can be as- 
similated. The stools should be carefully watched from day to day 
to make sure that the milk or other articles of food are thoroughly 
digested. Nourishment should be given at brief intervals, which 
must depend somewhat upon the amount of time allotted to sleep, 
but in cases of great exhaustion patients should not be permitted 
to go more than four hours at any time without food, and sleep 
must be interrupted for feeding, if necessary. In other cases when 
sleep so interrupted is readily resumed, food may be given with 
regularity once in two hours throughout the day and night, as in 
typhoid fever. When improvement is attained, the intervals of 
sleep will naturally be longer, and it will be both unnecessary and 
unwise to awaken the patient for feeding. The basis of the diet 
in most cases should be milk, and by studying the taste and 
digestion of the patient it is usually possible to prepare it in such 
a manner that it is well borne. (See Adaptation of Milk for the 
Sick, p. 73-) 

In commencing the milk diet the objection of the patient often 
has to be overcome, and it is advisable to begin slowly, giving 
skimmed milk in tablespoonful doses four or five times a day for 
two or three days until the patient is accustomed to it. Other 
food is of course allowed at first, but this is to be gradually reduced 
and the milk substituted for it in increasing quantity until four 
ounces of skimmed milk are taken every two hours. It is finally 
given up to eight or ten ounces at the same intervals. The taste, if 
disagreeable, may be overcome by the addition of a little black 
coffee or caramel. If it produces weight and epigastric oppression 
or causes flatulence and eructations it is to be diluted by one half or 
one third with lime, barley, or rice water or Vichy. One of the 
I prepared foods," such as Nestle's or Mellin's, may be added, or the 
milk may be pancreatinised or temporarily replaced by koumiss or 
zoolak. The exclusive milk diet tends to make the patient drowsy 



602 DIET IN DISEASE 

and to allay irritability in all the organs of the body, and it is actively 
diuretic. 

The constipation which the milk occasions may be overcome by 
a pill of ox gall or a dose of bitter water in the morning, or by 
enemata of warm soapsuds, when the latter do not produce the ex- 
haustion which occasionally follows their use. 

Many patients do very well on the exclusive milk diet for a 
week or two, and they may be fed very much as typhoid-fever pa- 
tients are, excepting that they may take more milk. If they can 
digest it, two and a half or three quarts a day should be given as 
recommended by Weir Mitchell, who was the pioneer of this method 
of treatment in this country. After five or six days of such treat- 
ment a chop or a poached egg may be added at noon. The next 
day bread and butter or bread and milk is given, besides, for supper, 
and then an egg or a little meat at breakfast, until the patient is tak- 
ing three good meals of plain food daily, but in addition at least two 
quarts of milk. The exclusive milk diet is believed to prepare the 
digestive system for the assimilation of other foods. 

Play fair's Diet 

Playfair's diet for neurasthenia is a good example of a milk diet, 
soon combined with other foods, as follows : 

First Day. — Twenty-two ounces of milk in divided doses. 

Second Day. — Fifty ounces of milk in divided doses. 

Third Day. — Fifty ounces of milk in divided doses. Massage, 
half an hour. 

Fourth Day. — Fifty ounces of milk in divided doses ; egg, bread 
and butter ; dialysed iron, forty minims in two doses. Massage, 
one hour and a half. 

Sixth Day. — Fifty ounces of milk in divided doses ; mutton chop. 
Massage, one hour and fifty minutes. 

Eighth Day. — Fifty ounces of milk in divided doses ; mutton 
chop ; porridge and a gill of cream ; maltine, twice daily. Massage, 
three hours ; electricity, half an hour ; continued to end of treat- 
ment. The solid food is now gradually increased until such a diet is 
reached as the following for the 

Tenth Day. — 6 a. m., raw meat soup, ten ounces ; 7 a. m., a cup of 
black coffee; 8 a. m., a plate of oatmeal porridge, a gill of cream, a 
boiled egg, three slices of bread and butter, and cocoa; 11 a.m., 
milk, ten ounces; 2 p. m., rump steak, one half pound of potatoes, 
cauliflower, a savoury omelet, milk, ten ounces; 4 p.m., milk, ten 
ounces; three slices of bread and butter; 6 p.m., a cup of gravy 
soup; 8 p. m., a fried sole, roast mutton (three large slices), French 
beans, potatoes, stewed fruit, and cream ; milk, ten ounces ; n p. m., 
raw meat soup, ten ounces. 



THE NERVOUS SYSTEM 603 

Fifteenth Day. — Three full meals daily of fish, meat, vegeta- 
bles, cream, and fruit; two quarts of milk and two glasses of Bur- 
gundy. 

Twenty-second Day. — Amount of food lessened. 

Ley den's Diet 

Leyden's diet for neurasthenia is a modified form of milk treat- 
ment which gives excellent results in some cases : 

At 7 a. m., half a litre of milk, slowly sipped in half an hour, a 
small cup of coffee with cream, eighty grammes (nearly three ounces) 
of cold meat, a mealy baked potato; 10 a.m., a litre of milk with 
three biscuits; 12 a.m., the same; 1 p.m., broth, two hundred 
grammes (about seven ounces) of fowl, puree of potatoes, green 
vegetables, one hundred and twenty grammes (nearly four ounces) 
of compote, and pastry; 3.30, 5.30, 8, and 9.30 p.m., half a litre of 
milk, making a daily consumption of three litres and a half of milk. 
In the after part of the day, two meals each of eighty grammes 
(three ounces) of roast meat with bread and three biscuits. 

Keating s Diet 

Keating's diet for neurasthenia is adapted to patients who need 
not be kept constantly in bed. It is as follows : 

At 6 a. m., a tumblerful of strong hot beef tea ; 8 a. m., a half tum- 
blerful of iron water, and breakfast of fruit, steak, coffee, and a 
goblet of milk ; 8.30 a. m., a goblet of milk with a dessertspoonful of 
malt extract, six grains of citrate of iron and quinine ; 10 a. m., elec- 
tricity ; 12 a. m., a goblet of milk and malt ; 2 p. m., dinner, preceded 
by a half tumblerful of iron water and a third goblet of milk and malt ; 
6 p. m., third dose of iron water. Light supper of fruits, bread 
and butter, and cream ; a fourth goblet of milk and malt ; 10 p. m., 
beef soup, four ounces, preceded by massage with cocoa oil for 
an hour. 

Two quarts of milk are taken daily, in addition to all other food. 
The patient on this diet is allowed to be out of bed for four hours 
every day, one of which may be spent in business. 

If milk can not be made to agree with the patient in any form, 
meat broths and purees and light farinaceous food may be prescribed. 
Eggs may be given dropped into bouillon or any of the preparations 
of egg albumin. Meat essences and extracts, such as Liebig's or 
Valentine's, are serviceable, but the latter are so merely for their 
stimulating effect upon digestion. If the condition of the stomach 
is good, the constipation resulting from so concentrated a diet may 
be overcome by the use of oatmeal porridge for breakfast, whole- 
meal bread, and fresh fruits, such as the juice of the shaddock or 
dried or stewed prunes. A reference to the receipts given at the 



604 DIET IN DISEASE 

end of this book for the several kinds of fluid food will enable the 
physician to prescribe sufficient variety to stimulate the appetite of 
the patient, and in many cases a slightly different menu can be or- 
dered for each day in the week. Most patients after a fortnight to 
three weeks of semisolid diet are able to digest meat and other 
solid foods. As an example of an excellent typical dietary for this 
stage of the treatment, the following is given by H. C. Wood : 

At 8 a. m., rolls or toast, cocoa, weak coffee or roasted wheat cof- 
fee, beefsteak, tenderloin, or mutton chop ; 9 a. m., bathing ; 1 1 a. m., 
oatmeal porridge with milk or else a half pint of molasses ; 12 noon, 
massage ; 2 p. m., dinner, bouillon with or without agg, beefsteak, 
rice, white potatoes roasted ; dessert of bread pudding, blancmange, 
or similar farinaceous articles ; 4 p. m., electricity ; 5 p. m., milk toast ; 
9 p. m., a half pint of skimmed milk or koumiss. 

Bilfinger believes that a modified vegetable diet is most useful in 
the treatment of neurasthenia, being less irritant to the nervous sys- 
tem than a preponderance of animal food, and for anaemic subjects 
who require proteids he prescribes milk and oatmeal porridge and 
preparations of ground meal of legumes. He allows chocolate and 
cocoa for beverages. A vegetable diet is useful in certain chronic 
cases in which the patient is much worried over the smallness and 
infrequency of the stools. Accompanied by large draughts of water 
such diet gives copious and ready evacuations. For this purpose 
such vegetables should be prescribed as celery, string beans, spinach, 
peas, and potatoes and beans in purees. Sago, rice, and cracked or 
shredded wheat may be also eaten. Meat should not be allowed 
more than once a day. Milk, butter, and cream toast are excellent 
foods for these patients. 

Electricity. — The use of the electric current is of service in pro- 
moting the nutrition of the body during the period of absolute rest 
from voluntary movement. It should be distinctly remembered that 
the electric current itself possesses no special nutritive value or 
"vitalising" influence, such as is often claimed for it, but that it 
acts favourably upon the muscular system by causing the muscles to 
contract, and in that way also quickens the circulation. The con- 
traction of muscles compresses the contents of their lymphatic ves- 
sels and venous radicles, thereby aiding circulation, while the phe- 
nomena are accompanied by metabolism which involves the appro- 
priation of the ingredients of the food which have been absorbed. 
The faradic current is used for this purpose. It may be applied 
to special groups of muscles at first, and subsequently to the entire 
body. Care should be taken not to fatigue individual muscles, and 
the current should be carefully regulated and applied in accord- 
ance with the condition of the patient. The use of electricitv in 
relation to the treatment of constipation has been referred to under 
that heading. It is doubtful whether the local application of elec- 



THE NERVOUS SYSTEM 605 

tricity over the abdominal wall exercises any definite influence upon 
the digestive processes which may be going on in the viscera beneath 
the electrodes. 

Insomnia and Disordered Sleep 

Insomnia is due to many causes, but those which concern die- 
tetics are the opposite extremes of overfeeding and starvation or in- 
anition. Overfeeding or eating improper food may cause disordered 
sleep, nightmares, or temporary insomnia from attacks of acute in- 
digestion, dyspepsia, or biliousness, but inanition or malnutrition is 
more apt to cause true insomnia from exhaustion. Neurasthenic 
subjects whose nerve energy is insufficient to conduct their digest- 
ive and absorptive functions completely are very liable to suffer 
from insomnia. They unfortunately resort to hypnotic drugs in- 
stead of first trying the efficacy of dietetics. 

It is a good rule in such cases to improve the nutrition by care- 
fully regulated feeding at frequent intervals. In addition to three 
good meals a day, the patient should be made to take one or two 
quarts of milk, with beef tea and one or two ounces of malt extract. 
By gradually increasing the diet according to such rules as those 
given for the treatment of neurasthenia, in a week or ten days the 
patient can often be made to reach the maximum above given, and 
improvement is almost certain to follow. It is best to take the 
heaviest meal of the day in the early afternoon not as late as six 
o'clock, for an overloaded stomach with indigestion is itself a cause 
of insomnia, but, on the other hand, going to bed with a perfectly 
empty stomach is usually undesirable. In mild cases a glass of hot 
milk, a couple of teaspoonfuls of meat extract in hot water, or a 
cup of good beef tea and a biscuit, or a cup of cocoa, or chicken 
broth, or a light sandwich and a glass or two of beer or ale, taken 
just before retiring, will serve to divert the blood current from the 
brain to the stomach and induce cerebral anaemia and sleep with- 
out the use of medicines, stimulants, or " nightcaps," and if anodynes 
have to be given, a little food taken in this manner increases their 
efficacy and makes a smaller dose possible. 

Vertigo 

Vertigo, although it arises from many causes, may be occasioned 
by digestive disorders, such as the production of flatulency and pal- 
pitation, or by the absorption of products of indigestion which act 
as irritants of the vascular system. Such products, for example, are 
developed in some persons by eating shellfish, strawberries, etc. 
(p. 378). Lack of sufficient food may cause it. 

The dietetic treatment is that of dyspepsia (p. 521). Fats, sugars, 
and starches are forbidden, and alkaline and laxative waters, such as 



606 DIET IN DISEASE 

Vichy, Congress, or Hathorn water, are of service to open the bow- 
els and increase the activity of the kidneys. Lithsemic cases should 
be kept for a week or two upon a vegetable diet (p. 504). 

Chorea 

Mild cases of chorea require no special regulation of diet beyond 
that which is directed towards the prevention of flatulent dyspep- 
sia (p. 525) and constipation (p. 571). In more pronounced cases 
it is sometimes advisable to put the patient for a time upon a 
milk diet. Sweets and farinaceous foods should, as a rule, be for- 
bidden for fear of increasing palpitation through exciting flatulence. 
Other patients do better with a diet of animal food, consisting of 
meat, fish, eggs, and oysters with bread and milk, koumiss, or mat- 
zoon. They are apt to be anaemic, and they should be encouraged 
to take as much food as the digestive organs will tolerate. Cod- 
liver oil is very useful in these cases. 

Epilepsy 

Epilepsy is a functional nervous disorder, which may often be 
considerably improved by careful attention to diet. A very large 
proportion of cases occur in childhood at a period when existing 
functional derangements of the nervous system are readily aggra- 
vated by improper food. Many rhachitic children with imperfect 
development of the teeth, feeble digestive organs, and consequent 
malnutrition develop epilepsy while teething. Of twenty-seven 
cases occurring among children recently analysed by Osier, more 
than one half developed before the fifth year and more than three 
fourths before the tenth year. Very many cases are closely asso- 
ciated with errors in diet or affections of the alimentary canal, and 
while such conditions may not cause the disease, they readily precip- 
itate epileptic seizures. This statement applies to grand mal and 
petit mal rather than to the localised or partial convulsions known 
as Jacksonian epilepsy, which are due to local and definite cortical 
motor irritation. Of the varieties of epilepsy, petit mal is more 
favourably influenced by diet than are the other forms. 

Patients should have their eating supervised with care. They 
should be well fed, but must eat only easily digestible food and have 
their meals at regular intervals, and the principal one must be in 
the middle of the day in order that digestion at night may be com- 
pleted before going to sleep. All food should be eaten slowly, and 
meat, if given, must be very thoroughly masticated, and the stomach 
should never be overloaded. 

As a rule, meat should be allowed but once a day. Some chil- 
dren with petit mal, or even grand mal, improve rapidly on a strictly 
vegetarian diet or on a bland diet of which milk, bread and butter, 



THE NERVOUS SYSTEM 607 

and simple starchy foods, such as rice pudding, cornstarch, Indian- 
meal pudding, etc., form the basis. I have seen cases of epilepsy 
among young children in which, while the medicinal treatment re- 
mained constant, a return to meat diet was invariably followed by 
convulsions, which were absent on a vegetable or exclusive milk 
regimen. 

As a rule, adults do not seem to be aided by dieting to such a 
degree as children ; nevertheless, they do well to take but little 
meat and to be abstemious and regular in their habits of eating. 
Dr. Mersan, of the West Riding Asylum, in England, tried the ex- 
periment of putting a number of chronic epileptics for some weeks 
first upon a diet of flesh and then upon a vegetable diet, and vice 
versa. The results showed that their convulsions were not materi- 
ally lessened in number or severity, but it was noticed that while 
their food consisted largely of meat their mental condition was more 
stupid. At the epileptic colony of Chalfont St. Peter, the patients 
are allowed meat once a day, but all the inmates are men, leading an 
active outdoor life, and hence better able to digest stimulating pro- 
teid food. Gowers allows his patients meat twice a day, and asserts 
that he has seen cases in which fewer epileptic seizures occurred 
while eating flesh than when abstaining from it. One patient had 
paroxysms only after eating beef, but not in connection with other 
varieties of meat. It is evident that no definite rule should govern 
all cases. It is worth while to reduce the nitrogenous food for a 
month or two, and if improvement does not follow, or nutrition be- 
comes less active, it may again be added to the dietary. 

Dr. Whitmore Steele, formerly of the Utica State Asylum, in 
speaking of the treatment of chronic epilepsy at that institution, 
informs me : " We endeavour to reduce the amount of albuminous 
foods, giving a more liberal and easily assimilated diet also. Invari- 
ably overalimentation in our epileptics produces attacks." Epi- 
leptics will often gorge themselves with food and drink if allowed 
to do so. 

Some of the carnivores, as well as animals accustomed to a 
mixed diet, develop convulsions from a too liberal allowance of 
meat, if at the same time they are kept in confinement. In these 
cases, however, the convulsions may be due to reflex irritation from 
the stomach or bowels, produced by large masses of slowly digested 
food, rather than to the chemical nature of the food. The same 
thing may occur in young children who are allowed to gorge them- 
selves with any hastily eaten bulky diet, and the resulting convul- 
sions should not be confounded with genuine epileptic seizures 
accompanied by loss of consciousness, and recurring periodically- 
Some patients have a distinct epigastric aura preceding the convul- 
sions. 

It is extremely desirable to prevent intestinal putrefaction. 



<6o8 DIET IN DISEASE 

Should the stools become offensive, or much flatulence or indi- 
canuria appear, the patient should be given a milk diet for a week or 
two, and cathartics and intestinal antifermentatives should be em- 
ployed, such as salol, creosote, or guaiacol carbonate. 

Many are obliged to take large doses of the bromides and other 
medicines. It will be found that the disagreeable symptoms of 
bromism are much less apt to occur if the diet be so regulated as to 
carefully avoid constipation and to insure the consumption of abun- 
dant fluid diluents. Vichy or carbonic-acid water and water should 
be drunk freely between meals, and especially after taking medicine, 
and daily thorough evacuations of the bowels should be secured by 
the use of fresh vegetables and fruits, prunes, figs, apples, oranges, 
etc. Adults should abstain from agents which are likely to over- 
stimulate the nervous system, such as alcohol and strong tea and 
coffee. The use of tobacco should also be interdicted. 

Beri-beri 

Beri-beri is a form of multiple neuritis very rarely imported into 
this country by Chinese, Ceylonese, Japanese, or Philippine Island- 
ers, who have acquired it in their native countries or on the voyage. 
It is characterised by anaemia, general oedema, and more or less 
stiffness and paralysis of the extremities, with dyspnoea and serous 
effusions. Sometimes there are muscular spasms. 

Beri-beri has been attributed to the absence of fresh animal food 
from the diet, a sort of antithesis to the cause often assigned to 
scurvy. It has more specifically been attributed to the excessive 
consumption of rice and adzuki beans to the exclusion of other food ; 
but these views are incorrect, for upon the authority of Baelz it is 
stated that the best fed and best nourished are frequently subject to 
the disease. In the Japanese navy, where the disease was formerly 
not seldom encountered, it has been practically exterminated by in- 
creasing the nitrogenous-food ration and lessening the carbo- 
hydrates. 

The latest view of the disease is that it is not caused by bad food, 
but by a micro-organism, and that bad food and bad hygiene are 
merely predisposing factors. 

Locomotor Ataxia 

Locomotor ataxia is a disease which cannot be said to be particu- 
larly influenced by any system of dietetic treatment, although it is 
believed by some writers that the quantity of meat ordinarily eaten 
should be reduced. As in many other forms of very chronic nervous 
disease, a generous diet is desirable, with an abundance of fat, butter, 
cream, cod-liver oil, etc., when the stomach will tolerate it. Strong 
liquors should be forbidden, but light wines, malt liquors, tea, and 



THE NERVOUS SYSTEM 609 

coffee may be allowed in moderation. A reasonable use of tobacco 
need not be proscribed. 

In those cases in which the " gastric crises " predominate the 
diet must be restricted for a few days when the crises occur, upon 
the principles established for the treatment of gastralgia. (See Gas- 
tralgia.) It may be necessary at such times to put the patient upon a 
simple milk diet. 

Other diseases of the spinal cord do not usually demand particu- 
lar dietetic treatment, but Bauer says that " some diseases of the 
spinal cord lead to an extraordinary falling off of the demand for 
nutriment." This is due to alterations in general metabolism, which 
is further evidenced by a marked reduction in temperature. 

Apoplexy 

The several forms of cerebral haemorrhage may interfere with 
nutrition in a variety of ways. If coma is present, voluntary degluti- 
tion being suspended, great care must be exercised in feeding the 
patient. Liquid food is best given in teaspoonful doses, and the 
effect of each spoonful must be carefully watched to see that it is 
successfully swallowed before another is given, otherwise fatal chok- 
ing may result from food passing over an insensitive epiglottis and 
larynx, when particles of food may be drawn into the lungs and ex- 
cite local disease. Concentrated meat extracts, beef peptonoids, and 
peptonised milk may be given in this manner. 

In extreme cases, when rigidity of the jaw interferes with feeding, 
or when paralysis involves the mechanism of deglutition, a long, 
slender catheter may be introduced through the nose and passed 
into the stomach, through which fluid nourishment is poured, after 
the manner of feeding patients suffering from melancholia. (See 
Melancholia, p. 610.) 

The rectum may also be utilized for nutrient enemata (p. 408). 
In unilateral facial paralysis without unconsciousness patients may 
be willing and able to swallow, but mastication is difficult or impos- 
sible. The food constantly gets into the buccal cavity behind the 
teeth of the paralysed side, and the tongue, perhaps also partially 
paralysed, dislodges it with great difficulty. The retention of food 
is accompanied by a copious secretion of saliva, which, dribbling 
from the depressed angle of the mouth, adds greatly to the discom- 
fiture of the patient. All nourishment should therefore be given in 
fluid form, or in such finely divided state that it does not require 
mastication, and can be readily washed down with water. Milk, 
thick broths, purees thickened with macerated vegetables, long-boiled 
rice, sago, or barley with cream, custards, soft-cooked eggs, etc., 
may be given. The patient should be fed very slowly to prevent 
the food from running out of the mouth. The mouth should be 



6lO DIET IN DISEASE 

frequently cleansed with listerine or a saturated aqueous solution 
of boric acid. In cases of hemiplegia without facial paralysis the 
patient can masticate and swallow, but the mental condition or loss 
of appetite makes the use of food which can be swallowed with the 
least possible effort desirable. Convalescent hemiplegic cases which 
run a very protracted course naturally suffer from lack of exercise, 
and almost invariably become constipated. It is well in such in- 
stances to recommend simple and non-nitrogenous diet, containing 
laxative food, cooked fruit, and coarse cereals, to regulate the 
bowels. It is important to reduce arterial tension, to prevent, if pos- 
sible, a repetition of the intracranial haemorrhage. Large draughts 
of fluid rapidly absorbed tend by adding to the volume of the blood, 
to temporarily increase the intravascular pressure. The blood ves- 
sels, however, show a very remarkable ability to maintain an aver- 
age pressure of the fluid within them, and the possible danger from 
this source of an exclusive fluid diet may be averted by increasing 
the functional activity of the kidneys by diuretics and reducing the 
arterial tension by the remedies in common use, such as chloral, 
nitroglycerin, and the nitrites. When the tension is very high, it 
is well to give a non-stimulating diet without much meat, and milk 
should form the basis of it. Alcoholic stimulants should be for- 
bidden. 

Acute Insanity — Melancholia — Primary Dementia — 

Mania 

Acute insanity may result from overwork or severe mental strain, 
or from numerous diseases. It overtaxes the vital powers and causes 
wasting, inanition, and exhaustion. As the symptoms may result 
quite suddenly, often within a few hours after intense emotional 
strain or excitement, the digestive system is at first not necessarily 
disturbed to any considerable extent, although the appetite may be 
entirely absent. Subsequently various digestive disorders and mal- 
nutrition may supervene. 

The insane, especially the melancholic, often refuse food abso- 
lutely, or can be induced to take it only very sparingly. 

Forced Feeding. — When food is absolutely refused by the pa- 
tient, the question of forced feeding must be considered in order to 
tide him over the emergency and support life until confusional in- 
sanity or delirium subsides. 

Concerning this problem opposite views are held. Some alien- 
ists regard the operation of compulsory feeding as good mental dis- 
cipline, others decry it, and defer it as long as possible. It must be 
understood that the refusal of food may be either a complication or 
a symptom of the special form of insanity in which it occurs, and the 
patient should be carefully studied to determine which condition is 



THE NERVOUS SYSTEM 6ll 

present. As a complication, it may be caused by central nerve 
lesions that hinder deglutition, such, for example, as those found in 
either acute or chronic paralytic dementia. Or digestive disturb- 
ances, dyspepsia, or gastric catarrh may cause a loss of appetite 
which in the patient's disturbed mental state is exaggerated into a 
refusal of all food. Such local disorders may themselves cause hal- 
lucinations or delusions, giving rise to " sitophobia," or horror of 
taking food. Obviously in such cases cure of the complication may 
be sometimes effected by treating the local condition. Lavage will 
sometimes relieve it entirely. 

When the refusal of food is purely a symptom of the disease, as 
it occurs in melancholia or delusional insanity, an attempt should 
always be made to learn the exact nature of the delusion, and to try 
if it cannot be dispelled or offset, as in the case of some paranoiacs. 
For example, the delusion may apply merely to food cooked in par- 
ticular ways, or served in a certain manner or by certain persons, 
and the patient may have no real loss of appetite, but may even try 
to obtain food by stealth and be pleased at his success in that direc- 
tion, and his food should be placed where he can find it unobserved. 

Some patients will refuse all fluid foods who are willing to take 
solids, or vice versa, or they may refuse food offered by an attendant 
and yet accept it from a fellow-patient. 

If their delusions take the form of suspicion of poisoning, they 
may sometimes be overcome by showing them eggs in the shell, 
unpeeled potatoes and fruits, which obviously can not have been 
poisoned beforehand, and which are then cooked in their presence. 
Some patients will only eat if left alone or after others have fin- 
ished, because they feel unworthy to eat with them. Others who per- 
sistently refuse food will take it greedily if an apparent show of 
force is made in placing it within their mouths. 

Patients with chronic or asthenic mania may refuse food from 
inattention, although able to eat if their surroundings are quiet and 
their attention can be momentarily obtained. If they can be in- 
duced to take but a few mouthfuls at a time they should be fed re- 
peatedly at short intervals. 

Food should be cooked and served as temptingly as possible, and 
the patient, if unable to keep himself in order, should have his 
mouth cleansed and clothing protected from soiling. 

The appetite is seldom a safe guide in insanity, and when it fails 
completely forced feeding should not be postponed until the patient 
has become too exhausted to rally. Cases of depressive insanity are 
very apt to require it sooner or later, and sometimes it is practised 
continuously for a year or more. In acute mania, however, it may 
be only necessary to employ the method for a few days, after which 
the patient will eat of his own accord if given the opportunity. 

In cases of melancholia, after one or two feedings with the stom- 



6l2 DIET IN DISEASE 

ach tube, I have often, by a little firmness and patience, satisfied the 
patient that swallowing a glass of milk for himself was more agree- 
ble than having it poured in through a tube. When voluntary star- 
vation is the fixed intent, if the patient can be convinced that he has 
got to take food in some manner, he may yield to the inevita- 
ble and choose the lesser of what he regards as two evils. With a 
stomach tube in one hand and a glass of milk in the other the argu- 
ment can be made very forcible. 

The physician himself should always direct the passage of the 
tube for the first few times. Afterwards, if the patient is not refrac- 
tory, an attendant may do it. Occasionally the aid of two or three 
assistants is necessary to overcome resistance. The patient should 
be made to sit down or lie upon his back, and either an oesophageal 
or nasal tube may be used, according to the directions given on p. 
539. There are certain advantages in the use of each tube. The 
oesophageal tube does not so readily admit of regurgitation alongside 
of it as the nasal tube does (although occasionally patients can re- 
gurgitate through the tube itself). If it be filled before it is inserted, 
and if a little fluid be squeezed out of it when part way down the 
oesophagus, reflex swallowing occurs, which may be taken advantage 
of to further propel the tube. The disadvantage of this method of 
feeding is that the patient often struggles and must be gagged. A 
wooden gag shaped like a bit, with a central perforation through 
which the tube is passed, prevents it from being compressed by bit- 
ing. But the gag is disagreeable, it may slip and break a tooth, and 
the head and arms must be rigidly held by two assistants. I have 
known a refractory patient with melancholia to bite off and swallow 
eleven inches of stiff oesophageal tube, which remained in the stom- 
ach for eleven days before it was ejected by vomiting ! 

The nasal tube possesses the advantage that it can be more 
easily introduced with much less struggling, but it has the disad- 
vantage that greater care is required to prevent passing it into 
the larynx, for the insane are sometimes strangely insensitive. The 
former difficulty can be obviated by getting the patient to speak, 
or by closing the tube after it has been inserted and before fluid is in- 
troduced, in order to make sure that breathing is not obstructed. 
This form of tube should be of as large a size as can be conveniently 
passed. A No. 8 catheter will serve. 

For forced alimentation it is necessary to give food in fluid form, 
and a quart of milk, with one or two beaten eggs, either raw or 
slightly cooked or made into eggnog, may be prescribed two or three 
times a day. Nutritious meat broths, thickened with barley, rice, or 
vermicelli and strained, or potato puree, may also be given through 
a large tube. Cream and cod-liver oil should be added to the diet. 
In a case reported by H. C. Wood, for six weeks the patient lived 
with the greatest benefit on six pints of milk and sixteen raw eggs 



THE NERVOUS SYSTEM 613 

taken daily. If an ounce of malt extract be added to oatmeal or po- 
tato gruel in milk, it soon makes the mass sufficiently fluid to pass 
through the tube. As this method of feeding prevents the saliva 
from commingling with the food, there is additional advantage in 
giving malt or diastase to replace it. 

For obstinate patients, feeding with the tube twice a day — at say 
8 a. m. and 5 or 6 p. m. — is sufficient, and a quart of food can be intro- 
duced at once, but more feeble patients may require feeding three or 
four times a day. If gastric catarrh or dyspepsia is present, pre- 
liminary lavage may be employed, and then food and medicines 
may be poured through the tube. 

Both hypnotism and primary anaesthesia under chloroform have 
been utilised in extreme cases to enable food to be given to the in- 
sane, but the latter method is only necessary or justifiable in very 
exceptional cases. 

Nutrient enemata are of little value in the feeding of the insane 
who resist feeding, for if the patient realises their use he can make it 
more difficult to be nourished in this way than by the stomach or 
nasal tube. 

Suralimentation. — Suralimentation is to be recommended when 
feasible. (See p. 464.) 

Brush says : " In acute delirious mania, in melancholia with 
frenzy, and in some of the maniacal seizures incident to the aged, the 
great importance of a liberal persistent use of milk, eggs, and animal 
broths cannot be overestimated." 

If patients will eat they should be given abundant nutritious food, 
such as tender meats, custards, cereals with butter, sirup, or cream, 
eggnog, thickened broths, purees, beef jelly, gruels, etc., which are 
made palatable to tempt the appetite, and the number of daily meals 
may be increased or nourishment may be given once in three hours. 
By diverting the blood current and nervous energy for digestive pro- 
cesses, the general nervous system and mental condition become 
soothed and quieted. Fresh fruit and fruit juices should be offered 
occasionally. 

Special Precautions. — In acute insanity there is a tendency for the 
body temperature to fall two or three or more degrees below the 
normal. This is especially true of those cases of primary dementia 
which are due to exposure and privation accompanied by severe 
mental strain, such, for example, as occur from shipwreck or from 
any form of severe sudden shock. While regulating the diet, there- 
fore, attention must be given to the preservation of the body heat, 
and the patient should be surrounded by uniform temperature, to 
be maintained in an overheated room or by hot-water bottles and 
warm clothing. Sustaining the normal temperature will facilitate 
the digestive functions. 

The insane must be closely supervised while eating. They often 



■6l4 DIET IN DISEASE 

bolt their food, when given too much at a time, in a manner that 
soon destroys digestion. In such cases all food should be given in 
a state of fine subdivision or fluid or semifluid form. Patients with 
advanced general paresis or different paralytic diseases may easily 
suffocate by getting a piece of meat in the larynx. Patients with 
mania gravis, or suicidal melancholia, etc., should of course never be 
intrusted with knives or with plates or dishes which can be easily 
broken into sharp fragments with which to cut themselves. 

DIET IN SKIN DISEASES 

It has long been known that a relation exists between various 
errors in diet and certain skin diseases, but it is only within the past 
ten or fifteen years that attention has been directed to the importance 
of systematic dietetic treatment to aid the cure of such ailments, and 
a more thorough investigation of this subject is much to be desired. 

Skin Diseases which are caused by Improper Diet. — The skin dis- 
eases commonly referable among other influences to dietetic causes 
are erythema, urticaria, acne, eczema, and scorbutic eruptions. 

Many chronic skin diseases, if not originally caused by dietetic 
errors, are undoubtedly much protracted and made worse by them. 
This is particularly true of eczema, impetiginous and seborrhceic 
ecthyma, strophulus, and the cutaneous lesions of the tuberculous 
diathesis, and sometimes of psoriasis. 

The very important alimentary substance alcohol, when taken in 
excess, greatly aggravates many forms of chronic cutaneous lesions, 
notably those of syphilis and rosacea, and the capillary congestion 
and muddy complexion of chronic alcoholism is well known. 

The modes of production of cutaneous eruptions by dietetic 
errors are various. Probably in the majority of instances such erup- 
tions are due to malfermentation products, ptomaines, etc., which are 
absorbed through the digestive tract. In other cases they may be 
due to an effort to eliminate incompletely oxidised food products or 
poisons from the cutaneous glands (as in the case of drug rashes), 
and it has been suggested that they may be sometimes caused by re- 
flex nerve irritation from the alimentary canal, although the latter 
theory is less tenable. It is, however, interesting to observe the fact 
that an intimate relation often exists between irritation and inflamma- 
tion of the skin and of mucous membranes. Overeating, and especial- 
ly the overfeeding of infants, is a common cause of skin eruptions, 
and the attempted elimination by the sweat glands of fatty acids is 
irritant. 

General Principles of Dietetic Treatment. — There are certain gen- 
eral principles of dietetic treatment which are applicable to a major- ' 
ity of all severe cases. The food should be of simple kind, restricted 
in variety, and plainly cooked. Milk, meat, and stale bread are more 



SKIN DISEASES 6l$ 

desirable than amylaceous or saccharine food. If fever is present at 
the outset, a milk diet must be ordered. The tuberculous and gouty 
require fats in some form. Chronic cases with malnutrition and anae- 
mia must have abundant nourishing animal food. In the case of 
scorbutic eruptions the trouble arises sometimes (but not always) 
from malnutrition from withholding certain articles, such as fresh 
fruit and vegetables, from the diet. 

Substances to be particularly avoided in skin diseases are raw and 
unripe fruits and vegetables, sweets and pastry of all kinds, condi- 
ments and highly seasoned dishes, veal, pork, and alcoholic bever- 
ages. Other injurious foods will be mentioned under the treatment 
of the several varieties of skin diseases described below. 



Erythema — Urticaria 

Either acute erythema or urticaria may be caused in some per- 
sons by eating fish, and particularly shellfish and crustaceans, as oys- 
ters, clams, lobsters, shrimps, and crabs. It is also produced by straw- 
berries, bananas, and other forms of fruit. Crustaceans and straw- 
berries are perhaps the most common excitants. 

The action of the food poison is wholly different from that of 
ptomaines (p. 374), for it originates from fresh as well as stale 
food, and may be derived, as in the case of strawberries, from vege- 
table food. Some persons have an attack regularly every spring 
when strawberries first appear on the table. Others show occasional 
immunity, depending upon their condition at the time. Those per- 
sons who are hurt by one kind of poisonous food are not necessarily 
affected by the others. The whole matter seems to be influenced 
solely by idiosyncrasy. 

Other alimentary substances which have been observed to some- 
times poison are pork in various forms, sausages, mushrooms, 
cheese, and even mutton (Jackson). 

Symptoms. — The eruption develops suddenly and within from 
two to six hours after ingestion of the food. It is commonly a typ- 
ical urticaria with large pink wheals, which quickly come and go over 
all parts of the body. They are accompanied by intense itching and 
burning. This affection usually lasts but a few hours, or possibly for 
two or three days, though sometimes it may continue for several 
weeks. 1 

Treatment. — The eruption usually disappears upon withdrawing 
the offending article from the diet, and giving a saline cathartic and 
some simple remedy to regulate digestion and prevent fermentation, 
such as salol, salicin, or rhubarb and soda. Large quantities of water 
should be drunk. 

The troublesome itching is best relieved by sponging with com- 
mon baking soda, a teaspoonful to a quart of water, or a solution may, 
41 



6l6 DIET IN DISEASE 

be applied to the wheals of menthol and chloral, each a drachm, in a 
couple of ounces of a mixture of equal parts of alcohol and camphor 
water. A 1-40 carbolic-acid solution may be similarly applied. 

Acne 

Causation. — The larger number of cases of acne are produced by 
improper food. The papules and pustules which constitute acne 
are caused by inspissation of the oil of the sebaceous glands, which 
plugs their orifices and irritates the glands and the hair follicles, ex- 
citing inflammation in them. The disease is usually first observed 
during puberty, a period in which important changes in the nutrition 
of the body are in progress, and, once established, it is apt to last for 
some time — often for several years. It is easy to conceive how 
slightly altered composition of the blood, due to imperfect assimila- 
tion of food, may alter the composition of the sebum and irritate the 
sebaceous glands. 

In some people the papules appear as a result of eating buck- 
wheat cakes or oatmeal. In others they are caused by greasy food — 
doughnuts, sausages, cheese, fried meats, ill-cooked and rich pastry — 
excess of sweets, nuts, and other indigestible substances. 

Dietetic Treatment. — In addition to local means, the dietetic 
treatment of acne is most important. G. T. Jackson says : " The well- 
to-do are all prone to eat too much, and it is remarkable how rapidly 
acne will improve by reducing their diet to the simplest elements. In 
many of them a milk diet for a few days, provided milk agrees with 
them, will accomplish a marked benefit. It is a good rule to cut off 
from the dietary all pastry, cake, candy, sweets, hot breads and pan- 
cakes, greasy soups, articles fried in fat, twice-cooked meats, rich 
gravies — in fact, all those things that are most apt to tempt the 
palate." Alcohol in all forms should be prohibited, as well as tea 
and coffee. A tumblerful of hot water or a glass of Vichy should be 
drunk before each meal. With meals but little fluid should be taken, 
never over four or five ounces, but between meals water or aerated 
water should be drunk freely for its diuretic effect. Naturally, exer- 
cise, bathing, and the use of laxatives should be adjuncts to the die- 
tetic regimen. 

Eczema 

Causation. — Eczema, both acute and chronic, which constitutes 
so large a proportion of all cases of skin diseases, is provoked by 
different causes, but in a great number of instances its origin is 
directly traceable to dietetic faults. These may be of three kinds — 
namely, the eating of (1) too much food ; (2) insufficient food ; (3) 
improper food. 

1. Cases due to Overeating. — The ills of overeating have been 
elsewhere described (p. 366). Its relation to eczema consists in 



, 



SKIN DISEASES 617 

the additional burden thrown upon the skin of attempting to elimi- 
nate waste products, which are accumulated in the blood faster than 
they can be got rid of. The cutaneous glands, like the kidneys, are 
constantly stimulated and overworked, and the character of their 
secretion is altered. The skin, for a long time irritated, finally suc- 
cumbs to a definite eruption. 

It is for this reason that robust persons apparently in the best 
of health and with too vigorous appetites will sometimes be sur- 
prised with the sudden appearance of eczema, which they have al- 
ways attributed solely to " bad blood." 

Treatment. — This class of cases is to be treated by reducing the 
quantity of food, and by prescribing a very simple diet. In bad cases 
of general eczema it may be best to put the patient upon a milk or 
bread-and-milk diet for one, two, or three weeks. From two to two 
and a half quarts are taken daily with toast or crackers. Marked 
improvement will occasionally follow this course. For others, sim- 
ply reducing the diet by excluding meat and desserts for a time, may 
be all that is necessary. Meats — either beef, mutton, or chicken — 
should not be allowed more than once a day. Piffard reports that 
56 per cent of his patients were accustomed to eat meat in excess 
three times a day. 

Fish, either boiled or broiled, may be substituted for meat to 
advantage in neurotic subjects (Bulkley), for though it may excite 
urticaria, it does no harm in eczema in spite of the popular belief 
to the contrary. I have known the eating of shellfish, however, to 
intensify chronic cases considerably. 

Typical Diet for Eczema. — The following simple diet may serve as 
an example : 

Breakfast. — Bread and milk, or porridge, or wheaten grits, or 
cracked wheat, without cream, and salt or lemon juice may be added 
if preferred. Every other day a soft-cooked egg may be eaten. 

Dinner. — No soup, entrees, or dessert. Roast beef or mutton or 
chicken may alternate with broiled fresh fish with white meat, one 
or two green, light vegetables, such as haricots, spinach, lettuce, 
green peas, or macaroni. As Jackson says : " It is a good rule to 
tell the patient he may eat what he likes, but not of more than two 
dishes at a meal. It is unlikely that he will then overeat." Fresh, 
ripe fruits, except apples, may be allowed. 

Stepper. — Bread or toast or crackers and milk, custard, or simple 
rice pudding, not too sweet. A little fresh fruit. Stimulants are 
not usually required, but if needed for nutritive or tonic effect, di- 
lute liquor, brandy, whisky, or Hollands is the best form. 

Malt liquors of all sorts, as well as wines, should be forbidden. 
It is generally believed that tea and coffee are harmful in eczema, 
and drunk in excess they certainly are so, not only from disordering 
and retarding digestion, but from their undue stimulating effect. 



6l8 DIET IN DISEASE 

Unless they are taken in great moderation and but once a day, it is 
better to forbid their use entirely. The same is true of sweet choco- 
late, but cocoa may be allowed. 

2. Cases due to Insufficient Food. — Too little food results in im- 
poverished nutrition, and the skin, being one of the most sensitive 
organs of the body, is among the first to suffer. The habits of filth 
which so often accompany semi-starvation among the poor are con- 
tributing causes which combine to provoke skin eruptions. 

The diet required for these cases does not essentially differ from 
those of the preceding class. An effort should be made to restore 
the impoverished nutrition of the body as quickly as possible by 
suralimentation if necessary (p. 464). 

3. Cases due to Improper Food. — Improper food is also capa- 
ble of exciting outbreaks of eczema, and this is particularly true of 
chronic or relapsing cases. Oatmeal, for example, while it may not 
cause the disease, is generally believed to be capable of intensifying 
it. It is not possible to always forewarn against the particular arti- 
cles of diet which will do this, as they vary in different persons 
and often in the same person at different times, but, in general, food 
which is called " rich " is to be avoided, such as highly seasoned 
meats, soups, sauces, gravies, strong condiments, sweets, pastry, hot 
breads, pickles, preserves, and fancy desserts of all kinds. Bulkley 
especially forbids sweet potatoes, fried eggplant, cabbage, cheese, 
bananas, apples, soda water with sirups, as well as salt food, such 
as ham, corned beef, and salt pork. A little bacon or a salt herring, 
however, is permissible. All fried food, with the above exceptions, 
is strictly forbidden, and " fritters," fried oysters, etc., are highly in- 
jurious. In a word, all those articles which are liable to excite tem- 
porary dyspepsia and overload the urine with phosphates, urates, 
and calcium oxalate must be avoided. The staple diet should con- 
sist of whole-meal bread, fresh, plainly cooked vegetables, eggs, 
milk, and a little chicken, fresh fish, or meat not oftener than once 
a day. 

There are obstinate cases of chronic eczema which fail to yield 
to any dietetic regulations, but it is always desirable to thoroughly 
try the value of dietetics, and very often the result will be surpris- 
ingly gratifying. In conjunction with dietetic treatment the urine 
should be always carefully examined, and the bowels must of course 
be regulated. 

It is very important to control the general habits of the patient 
in regard to meals. He should eat at regular and proper hours and 
observe uniformity in the quantity of food consumed. He should 
be very careful to eat slowly and thoroughly masticate his food, and 
not drink so much fluid with meals as to dilute the gastric juice 
excessively. The general rules for the treatment of dyspepsia (p. 
525) and its avoidance are especially applicable to all skin diseases 



SKIN DISEASES 619 

which are in any way amenable to dietetic influence. It should also 
be remembered that eczema frequently is associated with gouty and 
strumous diatheses, and the reader is referred to the sections upon 
these subjects. 

ECZEMA IN NURSING INFANTS 

Bulkley points out that eczema in nursing infants is mainly due 
to dietetic errors of the mother, for whom, rather than for the child, 
treatment should be instituted. He prohibits the drinking of all 
forms of malt liquors and wines and rich chocolate. Anything 
which provokes indigestion and biliousness in the mother reacts un- 
favourably upon the skin disease of the infant. This is a very im- 
portant truth too often overlooked. If the mother becomes con- 
stipated, has dyspepsia and a furred tongue, and excessive deposit 
of urates and oxalates in the urine, her diet must be chang*ed, the 
bowels must be regulated, and tonics should be given. Other cases 
in infants are caused by the mother's milk being poor and thin, and 
the breast milk should be supplemented by cow's milk properly pre- 
pared, or it may become necessary to wean the baby completely. 
Mothers often nurse their infants too long, hoping thereby to post- 
pone conception. When the breast milk is too poor in quality Bulk- 
ley believes in adding fat to the baby's nourishment in the form of 
a few drops of cod-liver oil or a little cream, and he recommends 
inunctions of almond, sweet, linseed, or cod-liver oil. Cod-liver oil 
is cited by some authorities as causing eczema, but this refers to its 
use in excess when the digestion is deranged and dyspepsia is aggra- 
vated by it. Eczema is often cured by adding fat to the food. 

The common mistake of nursing infants too often is particularly 
apt to occur with eczematous babies, whose mothers mistake the 
child's crying for a manifestation of hunger, whereas it is often ex- 
cited by the extreme itching of the eruption, which the infant is too 
young or too feeble to scratch. If fed oftener than once in two hours 
or more, the infant's digestion becomes deranged, and any existing 
eruption is made more unbearable. Bottle-fed infants are more 
likely to have eczema than sucklings, probably because they oftener 
have gastro-intestinal disorders. Underfed infants are less subject 
to the disease than are the overfed. 

ECZEMA IN CHILDREN 

Eczema in young children is often due to dietetic errors, and in 
all cases care should be exercised to cure it by regulation of the 
food. The commonest fault in feeding young children consists in 
giving them too much starchy food, which they cannot as yet digest, 
and the innumerable prepared infant foods, consisting largely of 
starches and sugars, are responsible for much of this trouble. Some 
parents, aware of this fact, go to the other extreme, and give the 



620 DIET IN DISEASE 

child too much animal food in the form of meat juice, broths, and 
eggs. A diet improperly balanced in either direction induces an 
anaemic condition with a special tendency to the development of 
eczema. Older children should be denied candy, chocolate, and 
indulgence in sweets of all sorts, and must be fed upon the simplest 
diet, in which starch, and especially sugar, should be reduced, and 
pure fat increased. The latter is to be prescribed in the form of 
cream, fresh uncooked butter, fat beef, and cod-liver oil. Bulkley 
recommends the use of whole-meal bread, cracked wheat, hominy, 
and corn grits with salt and butter or cream. Oatmeal is prohibited ; 
likewise tea and coffee. 

EXFOLIATIVE DERMATITIS 

Exfoliative dermatitis should be treated upon substantially the 
same dietetic plan as eczema. An exclusive milk diet for a month 
or six weeks may prove beneficial. Jackson advises chewing flax- 
seed or taking, in milk, several ounces of flaxseed tea every day. 

Rosacea 

Causation. — Rosacea is a chronic skin affection disfiguring the 
middle parts of the face, about the nose, mouth, cheeks, and some- 
times the forehead, by red patches of dilated capillaries. . 

It is regarded as a reflex neurosis of the local vasomotor nerves. 
It is oftenest caused by erroneous diet, and especially by strong 
drink, which dilates the facial arterioles and also excites gastric 
catarrh. Jackson says : " The inordinate use of strong tea acts in 
the same way, and probably gives rise to as many cases as does 
alcohol." 

Dietetic Treatment. — The dietetic treatment is very important. 
It involves the prohibition of all alcoholic drinks, as well as hot 
beverages of every kind, such as tea, coffee, and soup. Existing dys- 
pepsia should be treated, and all rich food, desserts, sauces, pick- 
les, strong condiments, dried, salted, or canned foods, fried sub- 
stances, and sweets should be withheld. The patient must be kept 
for several weeks or months upon a low, non-stimulating diet of 
plainly cooked food, such as that advised for the treatment of eczema. 

Psoriasis 

Causation. — Psoriasis is a chronic skin disease characterised by 
the appearance of isolated red patches of considerable size, covered 
by shining white scales. The aetiology of this eruption is not under- 
stood. It may be hereditary or follow nerve shock, but in many 
cases it is directly attributable to imperfect assimilation of nourish- 
ment, and accumulation of waste products in the system, such as 



DISEASES ESPECIALLY INFLUENCED BY DIET 62 1 

occur in gout and rheumatism. The excessive consumption of oat- 
meal has been observed to cause it (Hardaway). 

Dietetic Treatment. — This disease is less amenable to dietetic 
treatment than are some other skin affections ; nevertheless, this 
must not be neglected, as it may prove a valuable aid to local meas- 
ures. The diet should always be restricted both in quantity and 
variety. Obese and plethoric patients improve upon a purely vege- 
table regimen. In bad cases it will be best to put them upon a 
bread-and-milk diet for a week. Vegetable food may then be added, 
but sweets and meats should be withheld. Feeble, anaemic patients 
usually improve upon an animal diet, consisting largely of milk, 
with eggs, beef, and mutton. Bread may be allowed. Elaborately 
cooked and highly seasoned food must be forbidden, as well as all 
forms of malt liquors. If any alcohol is required it should be pre- 
scribed in the form of well-diluted whisky and taken only with 
meals, but as a rule patients are better without it. 

Pruritus 

Patients suffering from pruritus should partake only of non-stim- 
ulating food. They must particularly avoid tea, coffee, alcoholic 
drinks of every variety, condiments, fish, pastry, cheese, sauces, 
pickles, made dishes, and fried food. Tobacco should be tempo- 
rarily withheld. 

FURUNCULOSIS, OR BOILS 

Furunculosis is often wrongly attributed to dietetic errors or high 
living, but it is now known to be of germ origin due to the action of 
the Staphylococcus pyogenes and other micro-organisms which pene- 
trate the skin, through abrasions or otherwise, so that the supposed 
influence of diet is only remote, in that poor living tends to lower 
the general vitality and make the body more susceptible to any form 
of inoculation. Special dietetic treatment becomes necessary only 
in debilitated cases, such as complicate anaemia, diabetes, or conva- 
lescence from protracted infectious diseases, and the rules for it will 
be found under those headings. 



DISEASES ESPECIALLY INFLUENCED BY DIET 

Obesity (Polysarcia) 

Causation. — Obesity is a diseased condition of the body, depend- 
ing upon alteration in the proper balance of nutrition, with an accu- 
mulation of fat in and between the tissues. 

It may affect either sex, but is much more common among 
women, in whom it is particularly noticed during and after the cli- 
macteric. 



622 DIET IN DISEASE 

It may develop at any age after early childhood. When appear- 
ing early it is usually the immediate result of heredity. It is, how- 
ever, most common after middle age, when the functional activity of 
the body is diminished and when habits of systematic exercise are re- 
placed by a sedentary life of luxury and ease, combined with over- 
eating. 

Aside from heredity, an important cause of obesity is excessive 
eating, which is a fault among the majority of persons who have 
passed middle life. When the growth of the body has been com- 
pleted there is a stage of equilibrium in weight which lasts for sev- 
eral years, and the waste matter of any excessive food taken is elimi- 
nated through the emunctories, which are kept active by exercise 
and work. After middle age, activity is considerably diminished, 
while the habit of fully satisfying a vigorous appetite may be con- 
tinued, resulting in the consumption of a larger amount of food than 
is required for maintaining the vital functions. It is extremely diffi- 
cult for people who feel in robust health and whose mental is pro- 
portionately greater than their physical activity, to realise that they 
not only require less food than they did ten, fifteen, or twenty years 
earlier in life, but that eating as they do they may be producing posi- 
tive harm by overloading the excretory organs. It is for this reason 
that many persons accumulate weight after reaching a certain ad- 
vanced period of life. 

According to Sir Henry Thompson's view, overeating in the first 
half or so of life may be relieved by occasional bilious attacks, which 
enable the system to cast off accumulated waste, but later " the un- 
employed material may be relegated in the form of fat to be stored 
on the external surface of the body or be packed among the internal 
organs, and thus he or she may become corpulent and heavy." 

The constant use of alcoholic stimulation in its milder forms, such 
as beer and ale, favours obesity, and in many individuals seems to 
be a direct cause of it. There are other cases in which it is difficult 
to attribute the accumulation of fat to any faults in either eating or 
drinking. Very stout persons are occasionally extremely moderate 
eaters, and in these cases the difficulty lies apparently in poor oxi- 
dation and insufficient exercise. 

The condition of obesity is somewhat modified by climate and 
race. It is less common in the United States than it is among eld- 
erly women in England and Germany. 

Not infrequently obesity occurs in connection with pronounced 
anaemia and hysteria. It prevents such patients from taking an ordi- 
nary amount of exercise. This is owing to the increased weight 
and difficulty of moving about, as well as to the lassitude and posi- 
tive dislike for muscular exertion which is felt by them. Obesity 
once established is likely to increase unless properly treated. 

So long as the fat is simply stored up as adipose tissue, and be- 



DISEASES ESPECIALLY INFLUENCED BY DIET 623 

tween and not within the cellular elements of the body, it is compara- 
tively harmless, excepting as it indicates a disproportion between 
functional activity and the amount of fuel taken in to develop force, 
and excepting also as it may interfere with personal convenience in 
movement and cause greater muscular fatigue from the increased 
work thrown upon the muscles in supporting so heavy a body. In 
other cases (and this may be the outcome of any advanced case of 
polysarcia) the fat may invade the cellular elements of the body, 
particularly the muscles, and fatty degeneration is produced in the 
muscular tissues, which very seriously weakens and impairs their 
functional activity. The special danger in all cases of this class is 
that the heart muscle may become affected in this manner, which 
renders it liable to cease beating whenever the slightest additional 
strain is thrown upon the circulation. It follows that it is most de- 
sirable in the dietetic treatment of obesity to determine the original 
cause of fat accumulation, and to ascertain to what extent it is ac- 
companied by fatty degeneration. 

Bauer says : " The fat stored up in the body acts in like manner 
with the fat contained in the food, since it likewise lessens the waste 
of tissue and secondarily the oxidation. Thus we understand why 
abstinence can be longer borne by organisms rich in fat than by 
those poorly furnished with it, the former consuming less of the 
albumin of their organs. The stock of fat stored up in the body is 
moreover the cause why corpulent individuals frequently continue to 
gain in bulk although they are not in the habit of indulging in food 
immoderately. 

" If an increase of albumin be desired without a considerable 
addition to the store of fat, a liberal allowance of albumin with rela- 
tively small quantities of carbohydrates must be provided. If, on 
the other hand, a substantial addition to the fat appear desirable, the 
food must contain less albumin and more carbohydrates, with a fair 
proportion of fats." 

Voit claims that albumin circulating in the blood is more readily 
oxidised than either fats or carbohydrates, and that the fat existing 
in the tissues acts like free circulating fat, not primarily by saving 
proteids from oxidation, but by causing a larger proportion of them 
to enter into the organised tissues, thus saving tissue waste. The 
tissues use up the circulating albumin, and, not being exhausted 
thereby, go on and oxidise the fat besides, and in this manner the 
store of fat in the body is reduced on a meat diet. 

An exclusive lean-meat diet increases the circulating albumin, 
and, the nitrogenous waste being correspondingly increased, fat does 
not accumulate in the body. If now fat be added to the diet, then 
fat is deposited in the body. 

The carbohydrates, like fat, can protect circulating albumin from 
destruction and aid its transformation to organic albumin, but it is 



624 DIET IN DISEASE 

not proved that they themselves make fat, as at first supposed, for 
they are very completely destroyed even when eaten in excess. They 
merely protect other foods from oxidation under such conditions. 

Meat and carbohydrates alone increase the fat in the body with- 
out the aid of fatty food, for fat, which originates from splitting up 
albumin, is spared further metabolism. Hence fatty metabolism in 
the body may be quite independent of fat indigestion. 

Dietetic Treatment. — The question of the treatment of obesity, 
owing to the frequency with which the physician has to deal with it, 
is a matter of great importance, and demands special consideration. 
The best results from treatment are obtained in patients less than 
thirty years of age. For a long time it was believed that excessive 
consumption of carbohydrates was the cause of increased fat produc- 
tion within the body. The pig is fattened on corn, and cattle upon 
various cereals. Undoubtedly, many persons who are of spare habit 
can increase their weight by eating a larger proportion of starches 
and sugars. It is a fact, moreover, that starches contain oxygen in 
the exact proportion necessary for the formation of water and carbon 
dioxide, and on being disintegrated in the body, they naturally pro- 
duce these two forms of waste matter which are promptly elimi- 
nated from the surface of the lungs and kidneys respectively. The 
proteid material of the food requires a larger percentage of oxygen 
for the metabolism involved in its complete conversion into urea. 

It is an undoubted physiological fact that the fat of the body 
may be made from a variety of different foods, and that some indi- 
viduals are capable of producing it from a particular class of food 
materials more readily than from others. Thus one person may 
become fat from overindulgence in saccharine food and another from 
eating purely starchy foods and taking large quantities of malt and 
beer, and still another from the excessive use of quantities of fat 
meat. Accordingly the rules which are formulated for the treat- 
ment of obesity must be regarded as referring to the majority of 
cases only, whereas there are many exceptions which must be indi- 
vidually studied. 

Many special dietetic systems are in vogue for the treatment of 
obesity. In some cases if the total quantity of food is diminished 
no special diet is necessary, but in many persons obesity is not due 
to overeating, but to other causes. Some patients improve at once 
when they give up all alcoholic beverages. An ounce of food eaten 
daily in excess of that which is eliminated, and which is capable of 
being stored in the tissues in the form of fat, very soon produces a 
considerable increase in the body weight, which in a year's time 
would amount to many pounds. 

Among the different systems which have been advocated for the 
cure of obesity the best known are those of Banting, Ebstein, and 
Oertel. Schweninger's cure is practically OerteFs method by with- 



DISEASES ESPECIALLY INFLUENCED BY DIET 625 

holding fluid from the meals, and giving all fluid at least two hours 
after ingestion of food. Schleicher's system is also similar to 
Oertel's. 

The principal systems which have been especially devised for the 
treatment of obesity will be separately discussed in detail. Nearly 
all of these systems agree in two principles : First, to reduce the 
total quantity of food ingested as much as possible without impair- 
ing the strength of the patient. Secondly, to diminish the amount 
of fluid drunk by prescribing what is called a dry diet. The treat- 
ment, moreover, is usually accompanied by systematic exercise or 
bathing, and it is highly important to keep the bowels active. 

Some persons attempt to cure obesity by allowing the patient to 
eat any food he chooses, but insisting that he shall eat only one kind 
of food at any one meal. As a natural result, the appetite soon palls, 
and he eats less than he otherwise would. This is an unscientific 
method, and an unwholesome one for serious cases. 

As a general principle, corpulent persons should restrain them- 
selves to as great an extent as possible from drinking fluids, espe- 
cially with meals. Exceptions to this rule occur when obesity com- 
plicates certain other diseases, such as gout or rheumatism, where 
the use of an increased quantity of fluid may temporarily be neces- 
sary in order to act vigorously upon the kidneys. 

Hot-water beverages taken half an hour before meals, and again 
at night and on rising in the morning, are beneficial, and less fluid is 
required with the meals. 

As a rule, never more than five ounces of fluid should be taken 
with a meal, or fifteen ounces per diem, and this amount may be still 
further curtailed by giving water between meals instead. 

Soups of all kinds should be forbidden as well as alcoholic bev- 
erages, and what little fluid is allowed should consist of plain or 
aerated water. But little, if any, milk should be taken. The food 
should be as dry as possible without interfering with its flavour and 
nutrient value. Highly succulent fruits, such as watermelons, and 
vegetables like raw tomatoes, which consist largely of water, should 
not be eaten. Sugar should be absolutely forbidden, and fat must 
be used very sparingly, and only in the form of a little butter. The 
allowance of farinaceous food must also be cut down as much as pos- 
sible. It will not usually be found practicable to do without bread 
for any length of time, but patients are often willing to restrict them- 
selves to a very rigid diet for two or three weeks if the positive hope 
of cure or amelioration of symptoms can be held out to them, if they 
are made to understand the rationale of the treatment, and if they 
are given some objective point to anticipate when a promised im- 
provement will admit of greater laxity in regard to diet. If desirable, 
gluten bread may be substituted for wheaten bread. 

The deprivation of starchy foods can always be better and 



626 DIET IN DISEASE 

longer tolerated if a little fat is given, and the obese do not well en- 
dure deprivation of all fats, even when starchy food is supplied in 
moderation. 

This is more often true of those engaged in mental work than of 
those employed in- muscular exercise. Salts and fresh green vege- 
tables — " vegetables which grow above the ground," except the 
legumes — should not be withheld. 

Lean meat should form the basis of all diet, but an unrestricted 
flesh diet in obesity may give rise to dyspepsia and gastric and intes- 
tinal catarrh. 

THE BANTING SYSTEM 

The diet which Mr. Banting practised upon himself and others 
with considerable success, and which bears his name, was exceeding- 
ly rigid in regard to restricting the quantity of food and in forbid- 
ding starches and sugars to the greatest degree possible. The pa- 
tients were starved to the extent of being allowed only between 
twenty-one and twenty-seven ounces of dry food in the twenty-four 
hours, about one half of which was meat. Only two ounces of bread 
could be taken, and the balance of the diet was composed of fresh 
fruits and the lighter forms of green vegetables. The fluid drunk in 
each twenty-four hours was reduced to thirty-five ounces. It should 
be remembered that the normal quantity of urine passed by an adult 
is, on the average, fifty-two ounces in addition to the water lost by 
perspiration and respiration. His dietary, which was based on the 
suggestions of his physician. Dr. W. Harvey, has been found too 
severe in many cases, and is apt to enfeeble the digestion, especially 
when patients are too quickly restricted in their food ; it is not pre- 
scribed in this country, excepting in modified forms. The fats and 
albuminoids are not well balanced in this diet, and it may cause con- 
stipation and malnutrition. 

Mr. Banting began his treatment upon himself in 1862, and in a 
single year lost forty-six pounds in weight. Sudden restriction in 
diet in obesity may sometimes precipitate attacks of renal or hepatic 
colic from the presence of calculi. Their deposition is brought about 
by altering the composition of the blood, and while practising any 
dietetic system for obesity one should be certain that the elimina- 
tion of waste matter from the system is not impaired, as it is if water 
is too suddenly withheld. On this account largely, the stricter diets 
for corpulency, such as the Banting system, sometimes result in fail- 
ure by producing a condition of the system which is far worse than 
the original corpulency. 

THE EBSTEIN SYSTEM 

The Ebstein treatment, as originally employed in Germany, has 
been attended with considerable success. The theory of this system 
is that animal as well as carbohydrate food is capable of being con- 



DISEASES ESPECIALLY INFLUENCED BY DIET 



627 



Comparison of Dietaries for Corpulence with Ordinary Dietaries (Atwater) 



Dietaries. 



Banting system j 

Ebstein system i 

Playfair's standard for "subsistence! 

diet" I 

Playfair's standard for adults withj 

moderate exercise 

Voit's standard for labouring man at 

moderate work 

Atkinson's standard for man withj 

light exercise 

Atkinson's standard for labouring man 

at moderate work 

Poor sewing girl, London ; diet barely 

sufficient for subsistence 

University professor, Germany; very 

little exercise J 

Well-to-do family, Connecticut ; foodj 

actually eaten 

Mechanics and factory operatives, 

Massachusetts ; food purchased. . . . 
Food actually eaten by college students: 

From Northern United States 

From Eastern United States 





NUTRIENTS. 




Protein. 


Fats. 


Carbo- 
hydrates. 


Total. 


Lr?'tZ7?l71ieS. 

171 

102 


Grammes. 

8 
85 


Gramines. 

75 
47 


Gra7ni7ies. 
254 
234 


57 


14 


34i 


412 


119 


5i 


53i 


70I 


118 


56 


500 


674 


100 


IOO 


360 


560 


125 


125 


45o 


700 


53 


33 


316 


402 


IOO 


IOO 


240 


440 


128 


177 


466 


77i 


127 


186 


53i 


844 


138 

104 


184 
136 


622 

421 


944 

661 



Potential 
energy in 



Calories. 
1,085 
1,400 

I,76o 

3.I40 

3,050 

2,8l5 

3,520 

1,820 

2,325 

4,080 

4,430 

4,825 
3,415 



verted into fat, especially when used in combination with starches 
and sugars. The latter are believed to furnish force for the body, 
and by their combustion to spare the complete oxidation of albu- 
minates, which are therefore stored in the tissues in a suboxidised 
form. It is a part of this theory that fatty food does not give rise 
to or promote the storage of fat in the body, and hence it may be al- 
lowed in the dietary ; in fact, Ebstein recommends its use on account 
of its effect in producing satiety. By sooner diminishing the ap- 
petite, there is less craving for other food and drink. In accordance 
with this belief, he proscribes the use of sugar, potatoes, and all 
forms of farinaceous food with the exception of three ounces and a 
half of bread, which is allowed each day. He permits the use of fats, 
such as fat meat, cream, butter, and fatty soups. Among vegetables 
he allows asparagus, spinach, cabbage, peas, and beans. A moderate 
amount of meat of any kind is also included. The quantity of fluids 
allowed is restricted. Ebstein allows the patient to take three meals 
a day. 

Breakfast consists of a cup of black tea without sugar or milk 
and two ounces of buttered toast. 

Dinner, which is given at noon, comprises a meat soup or broth, 
four to six ounces of boiled or roasted fat beef with meat gravy, not 
thickened, one or two fresh vegetables, in moderation, and for des- 



628 DIET IN DISEASE 

sert salads and fresh or dried fruits. He allows a little light wine 
and black tea without milk or sugar. 

Supper includes tea as before, a soft-cooked egg and a moderate 
allowance of fish, ham, or cold fat meat, an ounce of thin buttered 
bread or toast, and fresh fruit. , 

THE OERTEL SYSTEM 

A more recent system for the dietetic treatment of obesity is that 
practised by Oertel and modified by Schweninger. The distinctive 
feature of the Oertel treatment is the attention which is paid to im- 
proving the condition of the circulation by strengthening the heart 
action, and this, he claims, so much improves the general condition of 
the patient that the fat once eliminated is not reformed. According 
to his theory, corpulent patients may be subdivided into two different 
classes, whose diet is regulated accordingly. They are : 

" (a) Cases of fat accumulation in which the respiratory and cir- 
culatory apparatus have undergone no special derangement, and the 
patient is capable of muscular effort and locomotion. A much more 
serious form is that in which the condition of fatty heart is present, 
with consequent enfeeblement of circulation and visceral engorge- 
ment. 

" (b) Cases in which, in consequence of advanced stasis and 
hydraemia (with deficiency of haemoglobin), the amount of oxygen 
taken up from the lungs is extremely reduced, and the slightest 
muscular efforts are enough to disturb the respiration and provoke 
dyspnoea. " 

For the first class his maximum allowance of fat is fifty grammes 
and of carbohydrates two hundred grammes, with a minimum of one 
hundred and fifty grammes of albumin. For the second class the 
maximum allowance of fat is twenty-five to thirty grammes, with one 
hundred grammes of carbohydrates, but the albumin must consider- 
ably exceed one hundred and fifty grammes. In this class especially 
the amount of fluids drunk must be curtailed. By withholding fluid, 
Oertel argues, blood pressure is reduced, venous stasis is lessened, 
the vessels of the body will adapt themselves to the reduced quan- 
tity of fluid, and to supply the glandular organs and muscles with 
their normal proportion fluid will be " drained away from places 
where the tissue changes are less energetic, and which are less 
favourably innervated. Such vessels are, above all, in the fatty tis- 
sues — vessels branching in the panniculus adiposus." 

Nutritive changes ensue in the fatty tissues, the fat is disinte- 
grated, conveyed away, and burned up. 

This is certainly an ingenious, and withal very plausible theory 
which has many facts of clinical observation to recommend it. 

Besides holding the view that the fluid in the body must be re- 
duced before the accumulated fat can be diminished, Oertel says r 



DISEASES ESPECIALLY INFLUENCED BY DIET 



629 



" Since the force required to raise the body through a great height 
entails the destruction of large quantities of fat, the above exertion 
[mountain climbing] will also lessen the fat accumulation, on condi- 
tion only that we give less fat and carbohydrates in the food than are 
used up in the work done." 

He gives some fat and carbohydrate food, but not very much, 
with proteids, for he believes that, anaemia being present, an exclu- 
sive meat diet would not be completely oxidised. It is better, there- 
fore, to restrict all three classes of foods, but not to entirely exclude 
either, and the proteids must decidedly preponderate. 

He also believes that anaemia has weakened the vascular tone 
through supplying a blood deficient in circulating albumin, and 
hence a diet rich in proteids is further indicated. 

The Oertel system includes almost twice the quantity of animal 
food allowed in the Ebstein diet, and double the quantity of carbo- 
hydrates and less than half the quantity of fats. It is distinguished 
from the Banting system also by the greater preponderance of fats 
and starches. The following table from Yeo contrasts these differ- 
ent systems of diet. For comparison, the diet of Voit is added, 
which gives the proportion of the three chief varieties of foods upon 
which a man in health will decrease in weight. The figures repre- 
sent grammes : 



Daily 


Diet 








Albuminates. 


Fats. 


Carbohydrates. 




130 
140 
170 
IOO 

155-179 


84 
44 
10 

85 
25-40 


404 
165 

80 


Voit, " " 


Banting, " " 


Ebstein, " " 


50 
70-IIO 


Oertel, " " 





It will be observed that in all these diets the starches and sugars 
chiefly are proportionately much reduced, and the more liberal 
dietary of Oertel is particularly suitable for those classes of cases in 
which exercise can be joined with dietetic treatment. The combined 
effect of the diet with exercise results in the absorption and oxida- 
tion of the fat deposited between the muscular tissues and in the 
renewal of more vigorous action of the muscle fibres, which are 
shielded from waste by the liberal proportion of proteid food which 
is admitted. The whole treatment is aimed especially at increasing 
the vigour and force of the heart action, and in many cases it suc- 
ceeds admirably. In the more serious type of obesity the deposition 
of fat around the base of the heart as well as between and within 
the heart muscle fibres enfeebles the strength of the cardiac systole 
and results in engorgement of the venous circulation. The heart is 
unable to propel the blood through the arteries and capillaries, and 



630 DIET IN DISEASE 

there is very little vis a tergo remaining for the blood in the veins. 
Lack of exercise also retards the venous circulation. As a result, 
there is a constant venous congestion which is particularly notice- 
able in the viscera, and there may be dropsical accumulations in the 
different serous cavities or general anasarca. 

Exercise. — In the treatment of such cases Oertel withholds 
fluid from the diet as much as possible, and to assist the elimination 
of water from the body the patient is made to exercise by climbing 
carefully graded paths, which are measured and adapted with refer- 
ence to use by patients of different strength. During muscular exer- 
tion the destruction of non-nitrogenous food stuffs is increased. 

Palpitation and dyspnoea, which are so frequent accompaniments 
of excessive obesity, are not especially dreaded, and exercise is 
pushed until these symptoms occur — that is, the patients are made to 
climb the graduated ascents, walking slowly and systematically and 
covering a prescribed distance each day. As soon as they experi- 
ence palpitation, or if shortness of breath appears, they are to stop 
and rest standing until the breath is regained. In this way it is 
believed by Oertel that the heart action is actually strengthened, 
and the fat is certainly reduced. Of course, due care must be ob- 
served to prevent exhaustion, and the patients must be warned 
against any sudden movement or overexertion which might occasion 
fatal heart strain. This exercise by climbing ascents is sometimes 
called the " terrain cure." 

In case the patient is unable to take any exercise at all, the ob- 
ject is attained by massage and friction, and the promotion of per- 
spiration is secured by baths of different sorts. In the treatment of 
such cases, among the solid ingredients of the food, the fats and 
starches are still further reduced. 

Anaemia is believed to be counteracted by the use of albuminous 
food, and the following articles are allowed when this is a prominent 
symptom : Lean roast and boiled beef and veal, mutton, game, and 
eggs. Vegetables, spinach, and cabbage may be eaten. From four 
to six ounces of bread per diem are given, and fats and starches are 
restricted as much as possible, and sugars are withheld altogether. 
The fluid prescribed consists of a moderate cup (about six ounces) 
of coffee or tea or milk twice a day, with twelve ounces of wine with 
an equal quantity of water, which may be taken at dinner. If pa- 
tients perspire very freely, a somewhat larger quantity may be given, 
and no other beverages of any kind are permitted. 

The fluid allowed should not all be taken with the meals, but 
may be drunk at intervals between the times of eating to allay thirst. 
In the less serious type of cases, where the heart action is unim- 
paired, Oertel allows the fluid to be gradually increased, and he 
gives four to six ounces of wine at noon time, with a half bottle in 
the evening. 



DISEASES ESPECIALLY INFLUENCED BY DIET 63 1 

Bathing should be carried out systematically, and the patient 
may be packed with cloths dipped in hot water in order to promote 
perspiration. The baths are given at least twice a week through a 
period of a month or more. 

A typical menu under the Oertel treatment is the following: 

OertcVs Diet for Obesity 

Morning. — One cup of coffee or tea, with a little milk — altogether 
about six ounces ; bread, about three ounces. 

Noon. — Three to four ounces of soup, seven to eight ounces of 
roast or boiled beef, veal, game, or not too fat poultry, salad or a 
light vegetable, a little fish (cooked without fat), if desired, one 
ounce of bread or farinaceous pudding (never more than three 
ounces), three to six ounces of fruit, fresh preferred, for dessert. It 
is desirable at this meal to avoid taking fluids, but in hot weather or 
in the absence of fruit, six to eight ounces of light wine may be 
taken. 

Afternoon. — The same amount of coffee or tea as in the morning, 
with at most six ounces of water, and an ounce of bread as an ex- 
ceptional indulgence. 

Evening. — One or two soft-boiled eggs, an ounce of bread, per- 
haps a small slice of cheese ; salad and fruit, six to eight ounces of 
wine with four or five ounces of water. 

After patients have undergone a special course of treatment for 
obesity and their weight has been sufficiently reduced, it is desirable 
to establish a diet for them which will prevent a return of the fat. 
For this purpose Oertel recommends the following regimen ; it is 
intended for patients in whom obesity has complicated organic dis- 
ease of the heart or lungs : 

"Morning. — One cup of coffee or tea with some milk = 150 
grammes (6 ounces), and bread = 75 grammes (2 \ ounces). 

" Midday. — Soup =100 grammes (3 J ounces) ; lean meat, roast- 
ed or boiled, game or fowl = 200 grammes (7 ounces) ; fish, not too 
fat = 25 grammes (nearly 1 ounce) ; bread or starch stuffs =100 
grammes at most (3J ounces) ; as dessert 100 to 200 grammes (3^ to 
7 ounces) of fruit, fresh preferred — a smaller quantity if preserved, 
especially by Nagelis's method. Liquids are better avoided. At 
dinner time, only in very hot weather or in the absence of fruit, 
perhaps -§- to J litre of light wine may be allowed (6 to 9 ounces). 

" Afternoon. — The same quantity of coffee or tea as before, with 
at most -J litre of water (6 ounces) ; occasionally 25 grammes of 
bread (nearly 1 ounce). 

"Evening. — One or two soft-boiled eggs; meat, 150 grammes 
(nearly 5 ounces) ; bread, 25 grammes (nearly 1 ounce) ; a bit of 
cheese, a little salad and fruit. As a regular drink, £ to \ litre of 
wine (6 to 9 ounces), with perhaps J litre of water (4J ounces)." 
42 



632 DIET IN DISEASE 

Water should never be allowed in quantity, and what little is 
drunk should be distributed through the day. 

THE SCHWENINGER SYSTEM 

Schweninger's system is essentially that of Oertel, but the former 
absolutely forbids the use of drink of any kind with meals, and the 
little fluid that is permitted must be taken fully two hours afterwards. 

His treatment is substantially as follows : Moderate exercise for 
an hour before breakfast, after a cold bath with friction. 

Breakfast, 8 a. m. — Meat, eggs, or milk. A walk. 

Second Breakfast, 10.30 a. m. — Meat or fish and a glass of white 
wine. A walk. 

Dinner, 1 p. m. — Meat, vegetables, and fruit compote. 

Supper, 7 p. m. — Meat and fruit compote or salad, a glass of 
white wine. 

No other fluid is given with meals. Bread is eaten very spar- 
ingly. 

Schleicher's Diet for Obesity 

Breakfast, 7 a. m. — A mutton or veal cutlet or a portion of sole 
as big as the palm of the hand ; the same quantity of bread without 
butter. 8 a. m. — A cup of tea with sugar. 10.30 a. m. — A sand- 
wich of bread and meat or sausage. 

Noon. — Meat, eggs, green vegetables, cheese, an orange. Two 
glasses of white wine. (No soup, no potatoes.) 4 p. m. — Tea, with 
sugar. 7 p. m. — A small quantity of bread and cheese. 9 p. m. — 
Cold meat, eggs, salad. Two glasses of wine, and sometimes more. 

This is practically the diet of Schweninger, but without the abso- 
lute prohibition of drink at meals. 

THE GERMAIN SEE SYSTEM 

Germain See, who holds some original theories in regard to die- 
tetics, declares that the use of abundant drink is distinctly indicated in 
the treatment of obesity. He allows a diet of proteids and fats, with- 
holding sugars and starches, and requires his patients to drink hot 
weak tea and water in large amount. He prohibits alcohol in every 
form, excepting a little dilute wine, which may be allowed in excep- 
tional cases. His treatment is no doubt more serviceable in those 
cases of corpulency which complicate gout and rheumatism and in 
which, as above mentioned, it is desirable to eliminate the waste 
matter from the system as completely as possible. 

THE WEIR MITCHELL SYSTEM 

Weir Mitchell, for the treatment of obesity, relies mainly on rest 
and passive exercise in the form of massage and Swedish move- 
ments with a skimmed-milk diet, which latter may be given at in- 



DISEASES ESPECIALLY INFLUENCED BY DIET 633 

creasing rate, gradually replacing the accustomed food, until in a 
week's time the patient is living wholly upon milk. Upon this diet, 
the patient may lose half a pound or more in weight per diem. 
Careful watch is kept of the strength. The patient should be fre- 
quently examined with special reference to loss of weight and to 
any unfavourable increase in the heart action or feebleness of the 
pulse. If the latter conditions arise, it may be necessary to increase 
the diet or to give stimulation. A small quantity of beef, chicken, 
or oyster soup is allowed in such cases to relieve the monotony of an 
exclusive milk diet. The patient is kept quiet in bed for ten days 
or a fortnight, and afterwards permitted to move about the room, 
but must spend most of his time upon a lounge. Massage is per- 
formed once or twice a day at first, and subsequently the more 
active Swedish movements are applied to the extremities. After 
from four to six weeks of this treatment the weight is usually 
reduced by a number of pounds, and the general condition and 
strength are found to have improved. The diet is gradually in- 
creased by the addition of lean meats, beef, mutton, poultry, shell- 
fish, and boiled fish. For a long time, however, milk plays an 
important role, four or five glasses being taken daily. 

Weir Mitchell argues that so sudden a loss of weight as occurs 
in his treatment would be serious were the patient walking about, 
but when resting quietly in bed the danger of sudden exhaustion 
of the heart action is reduced to a minimum. His patients bear 
the treatment fairly well, and are frequently much pleased with the 
pronounced improvement in appearance and condition which they 
recognise. The treatment is not adapted to persons leading active 
lives who are unable to relinquish their business or other duties, 
for it requires a considerable length of time and the entire abandon- 
ment of all labour. 

THE YEO SYSTEM 

The diet recommended by Yeo is as follows : All fats and animal 
food are to be strictly limited, and farinaceous and starchy foods 
should be reduced to a minimum. Sugar must be entirely prohibited, 
but a moderate quantity of fat is allowed to secure the proper dilu- 
tion and digestion of the food. Hot water and hot aromatic drinks 
may be taken freely in the intervals between meals, especially in 
gouty cases. He allows the patient to drink a little hock and still 
Moselle, or light claret with alkaline table water. Beer, porter, and 
sweets of all kinds are to be prohibited, and no spirits should be 
drunk unless for some special need as a tonic. Meat is not to be 
eaten more than once a day, and not more than six ounces should be 
taken at any one time. The meat which Yeo allows is lean beef, 
mutton, lamb, poultry, game, and sometimes fish and eggs. Two 
lightly cooked or poached eggs may be taken once a day, or a little 
grilled fish. He allows thoroughly toasted bread in thin slices and 



634 DIET IN DISEASE 

crackers. Soups in general and milk, unless skimmed, milk pud- 
dings, farinaceous puddings, pastry, salmon, and mackerel must all 
be avoided. Fresh vegetables and fruits are allowed. He believes 
it is useless to attempt to give rules in regard to the actual quantity 
of dry food permitted, because it must necessarily vary in accord- 
ance with the weight and strength of the patient in each case. A 
quantity of food which might constitute an excess for one person 
would perhaps be insufficient to support the strength and activity 
of another. 

Later a full diet of meat may be allowed, but sugars and starches 
must still be excluded to as great an extent as possible. The patient 
may be taught to supplement passive exercise by calisthenics. 

THE DUJARDIN-BEAUMETZ SYSTEM 

Dujardin-Beaumetz believes that the diets allowed by Oertel and 
Ebstein are too restricted to support the body in a condition of nor- 
mal nutrition and activity, and his system of treatment is as follows : 
For the milder cases in which fatty degeneration has not yet invaded 
the heart and other viscera he gives half a pint of water or light wine 
diluted with Vichy, or some alkaline effervescent water, with each of 
the three meals of the day. Soup of all kinds is forbidden, wine or 
tea being recommended instead. If the gastric juice is apparently 
deficient, or if there is much dyspepsia, no fluid is allowed with the 
meals, but the patient is ordered to take a pint of weak tea without 
sugar or milk two hours after the completion of each meal. No 
other beverages are permitted excepting a small cup of black coffee 
with breakfast. Soup is also forbidden, and so is pastry. He allows 
dry bread in moderation, such as the outer part of Vienna rolls, or 
" soup sticks," which are chiefly crust, and he recommends animal 
food of all classes and several varieties of fresh vegetables and juicy 
fruits, such as oranges. For breakfast he gives three quarters of an 
ounce of dry bread, one and a half ounce of meat, and a cup of weak 
tea or a glass or two of light wine. Lunch is served at noon, and 
consists of double the quantity of bread and meat permitted at break- 
fast, with three ounces of fresh vegetables, salad, a small piece of 
cheese, and fruit. Eggs may be substituted for the meat, or fish 
may be given at either breakfast or luncheon. The quantity of the 
several foods allowed may be varied slightly. 

THE MEAT AND HOT-WATER TREATMENT 

This method is a treatment for obesity and chronic gastric 
catarrh, which consists in the restriction of the diet exclusively for 
several weeks to large quantities of rare beefsteak, and salt codfish 
and hot water for the first fortnight, three pounds of rump steak, one 
pound of codfish, with six and one third pints of hot water, are subse- 



DISEASES ESPECIALLY INFLUENCED BY DIET 635 

quently given for two or three weeks. The water is gradually re- 
duced to four pints, and lean beef and fresh fish may be eaten 
with dry toast or zwieback, and a very little green vegetable food. 
After five or six weeks the hot water is still further reduced to a quart 
a day, and dry crackers and dry toast and stale bread crusts, poultry, 
and game are added to the diet, and the patient may be allowed to 
drink hock diluted with carbonic or Seltzer water. The hot water, if 
desired, may be flavoured with fresh lemon juice, and five or ten 
grains of bicarbonate of soda are given twice a day. This treatment 
is found impracticable by many persons, who rebel against the ex- 
treme monotony of it, and are unable to eat so large an amount of 
meat either with or without other food ; it is principally adapted to 
persons who are habituated to overeating, and is not to be recom- 
mended for the majority of cases. 

THE BOUCHARD SYSTEM 

According to Bouchard's method, the frequent observation of the 
urine should form the basis of the treatment of obesity. When the 
nitrogenous waste is increased in the urine he reduces the allowance 
of animal food ; but he also believes, in opposition to many other 
theories of treatment of obesity, that the total quantity of farina- 
ceous and fatty food allowed should be five times greater than the 
quantity of animal food, and asserts that giving vegetable acids with 
the carbohydrates favours the oxidation of the latter. He therefore 
prescribes such fruits and fresh vegetables as are rich in the potas- 
sium salts of the organic acids. He forbids the use of vinegar and 
other acids, which he claims diminish the alkalinity of the blood 
and thereby increase the formation of fat. 

The patient's exercise is also governed by the elimination of urea 
and phosphates. When these salts are present in excess, he argues 
that the oxidation of the tissues is being unduly stimulated ; but if 
they are not present in too large quantity, exercise before meals is 
recommended. A review of the principles involved in this theory 
does not strengthen the belief in their value. 

The oxidation processes in the body are still too obscure to en- 
able one to take the urine as an absolute criterion of the conditions 
of metabolism, especially in those cases where a large reduction in 
the body weight is being obtained by the consumption of previously 
stored-up material. It is true that superfluous fat, when fully oxi- 
dised, leaves the body in the form of carbonic acid and water from 
the lungs, and in the form of water and carbonates in the urine ; 
but it is not definitely known to what extent this combustion spares 
the proteid materials of the body from disintegration and allows the 
animal food products to pass directly into the urine as urea or other 
nitrogenous waste matter. While the urine should be carefully stud- 
ied in these cases, a much better guide for the treatment of obesity 



636 DIET IN DISEASE 

is found in the observation of other symptoms and in the disappear- 
ance of previously existing abnormal conditions. 

THE CHAMBERS SYSTEM 

" Day's Regimen for a Three Weeks' Course. — Rise at 7. Rub the 
body well with horsehair gloves, have a cold bath, take a short turn 
in the open air. Breakfast at 8 or 8.30, on the lean of beef or mut- 
ton, cutting off the fat and skin, with dry toast, biscuit, or oatcake, 
a tumbler of claret and water or tea without milk or sugar, or 
made in the Russian way with a slice of lemon. Luncheon at 1 
on bread or biscuit, Dutch cheese, salad, water cresses, or roasted 
apples (without sugar or cream), hung beef, or anchovies, or red 
herring or olives, and such like relishes. Drink, after eating, claret 
and water, unsweetened lemonade, or plain water, in moderation. 
Dinner at any convenient hour. Take no soup, fish, or pastry, but 
plain meat of any kind except pork, rejecting the fat and skin. Spin- 
ach, French beans, or any other green vegetable may be taken, 
but no potatoes, made dishes, or pastry. A jelly or a lemon water 
ice, or a roast apple must suffice for sweets and dessert. Claret and 
water at dinner, and one glass of sherry or Madeira afterwards. 

" Between meals exercise, as a rule, in the open air, to the ex- 
tent of inducing perspiration, must be taken. Running, when prac- 
ticable, is the best form in which to take it." 

Chambers also advised giving liquor potassae with the proteid 
diet, or the remedy of Dancel, consisting of one half or a teaspoon- 
ful of sodium bicarbonate added to five or ten grains of tartaric acid 
in a small tumblerful of water, and drunk while effervescing. He re- 
stricted sleep to seven hours a day, for it is weakening for the obese 
to remain too long in bed in a close room. Turkish baths were also 
recommended. Chambers's further directions to be observed by the 
patient to prevent a possible return to corpulency were as follows : 
Continue to avoid fat meats, rich milk, butter, malt liquors, sweet 
wines, starches, especially pastry and puddings, and sweet vegeta- 
bles, such as parsnips and beets. 

The patient may have lean beef or mutton, venison, game, poul- 
try, boiled fish, poor new cheese, green vegetables and fresh fruits, 
oranges, lemons, almonds, roast apples, salads, olives, buttermilk, 
claret, hock. Bread should be aerated or toasted. Captain's bis- 
cuits may be eaten. Among the green vegetables which may be 
eaten are tomatoes, celery, stuffed red and green peppers, radishes, 
asparagus, artichokes, oyster plant, squash, and spinach. 

Of the various systems above described, that of Oertel is, on the 
whole, the best adapted for the greater number of cases. The Eb- 
stein treatment diminishes the appetite and is useful for robust 
patients, but if there is enfeebled digestion and weakness, this diet 
is not to be recommended on account of the large proportion of fat 



DISEASES ESPECIALLY INFLUENCED BY DIET 637 

and the relatively small amount of proteid foods. Schweninger's 
system has the disadvantage that although the withholding of all 
fluid at mealtime lessens the capability of taking solid food in ex- 
cess, there are many persons in whom the gastric juice is deficient in 
quantity, and its proper action can only be secured by dilution with 
a moderate amount of fluid during gastric digestion. The Banting 
method, besides being too rigorous for many, has the disadvantage 
of allowing no fat to be eaten. 

The essential value of all methods of dietetic treatment of obesity 
is based upon two objects to be attained : First, to enable the pa- 
tient to fully oxidise and eliminate the fat which is already accumu- 
lated in various parts of the body, and, secondly, to make it impos- 
sible for it to be reformed. 

From what has been said of the cause and nature of obesity, it 
follows that no one system of treatment is applicable in every in- 
stance. The effect of any treatment should be observed from day 
to day, care being taken that the patient while losing flesh does not 
at the same time lose in strength to a degree which may become 
dangerous — i. e., more than two or three pounds per week. Fre- 
quent examinations should be made of the heart action, the circula- 
tion, and the urine. 

The favourite baths in Europe for the treatment of obesity are 
Carlsbad and Marienbad, but there are many others. 

The thyroid-gland extract has a remarkable effect in reducing 
obesity in some cases, even without accessory treatment. The cat- 
abolism of the process is not understood, but the C0 2 elimination is 
increased, and in addition to increased consumption of fat tissues 
there is increased nitrogenous waste. The effect is not permanent, 
and the lost weight is soon regained if the patient fails to persist in 
dietetic treatment with exercise. The powdered gland is given in 
tablet form, in doses not exceeding five grains three times a day. 
It is best not to give more than five grains at first in twenty- 
four hours, for the remedy sometimes produces serious cardiac 
weakness and digestive disturbance. I have usually found that 
after a reduction in weight of about thirty pounds the use of the 
extract had to be discontinued. 

"ANTI-FAT" REMEDIES 

A host of quack nostrums are offered to a credulous public un- 
der the claim that they reduce corpulency. Some of them have 
achieved reputation because while they are taken the patient is also 
induced to regulate his diet ; others merely because they have de- 
stroyed the appetite or digestion and have made it impossible to eat 
too much food. But the whole lot of " reduction pills," concentrated 
salts and purges, extracts of phytolacca berries, Fucus vesiculosus, 
and other so-called " specifics " for reduction of obesity, cannot be 



638 DIET IN DISEASE 

too strongly condemned as thoroughly unscientific, if not positively 
harmful or dangerous, as many of them are. 

It cannot be expected that any chemical remedy can control the 
complex processes involved, and the substances which are in exten- 
sive use by credulous persons for this purpose diminish the appetite, 
impair the digestion, and seriously interfere with nutrition. 

Excepting the thyroid extract there is no drug or remedy known 
which acts specifically either in retarding fat formation or in causing 
its destruction in the body, and when any such remedy appears to 
have that effect, it is acting indirectly by a general lowering of 
vitality. 

Diet for Leanness 

The foods which tend to produce fat in the body are chiefly 
sugars and starches. Eating fat in excess does not necessarily cause 
fat to accumulate in the system, for it may be completely oxidised. 

To increase the albuminous constituents of the body without the 
accession of fat, a diet should be ordered in which proteid food pre- 
dominates, with a moderate allowance of carbohydrates. To in- 
crease the body fat, however, the proportion of carbohydrate should 
considerably exceed the proteid food and a little fat should be added. 

In seeking to remedy excessive leanness by dietetic treatment it 
is obviously necessary to first ascertain, if possible, its cause. It 
may be due to the use of improper food, to erroneous habits of eat- 
ing, bad cooking, maldigestion or malassimilation, overwork and 
nervous exhaustion, disease of the various organs connected espe- 
cially with nutrition, and besides these and other causes there are 
those in whom leanness seems to be constitutional or hereditary. 
They may enjoy excellent health, but are always so thin as to be the 
subject of comment. No diet seems to have much effect in increas- 
ing their weight. Another class of persons are those whose weight 
is constantly fluctuating and whose annual variation is as much as ten 
or even twenty pounds. In winter, in town life, when overworked, 
worried, or oppressed with mental strain, they lose weight rapidly, 
and in summer, in a brief holiday in the country, with little to do 
but eat and sleep, they gain at the rate of two or three pounds a 
week. This is true more often of those whose general tendency is 
towards obesity rather than towards leanness. 

It is almost hopeless to attempt to remedy obstinate leanness by 
diet unless other favouring conditions can be secured. First among 
these is entire freedom from mental strain, and of almost equal im- 
portance is abundant and regular sleep. A warm climate and inac- 
tive life favour increase in weight. In most respects the diet for 
leanness must be the reverse of that for obesity, as would be natu- 
rally expected, and in prescribing starchy foods it must be remem- 
bered that the leanness is often caused solely by an entire inabilitv 
to digest amylaceous or saccharine material owing to " nervous dys- 



DISEASES ESPECIALLY INFLUENCED BY DIET 639 

pepsia," gastric catarrh, etc. These conditions should receive careful 
treatment on the lines recommended on pp. 526 and 528. By a 
little care it will often be found possible to find some forms of 
starches which can be digested. It is a good rule in such cases to 
give the cereals or vegetables at one meal and meat at another, so 
that articles involving different rates and organs of digestion do not 
interfere with each other. All bread should be stale or toasted. 
Crackers and zwieback may be allowed. As a rule such patients can 
be made to digest starches before they can sugars — oatmeal will be 
better digested without sugar, and a cup of sweetened coffee with a 
meal of starchy foods may produce flatulency which lasts for hours. 

When the digestive organs admit, the following articles may be 
prescribed in the diet for leanness : 

Abundant fat meats, butter, cream, milk, cocoa, and chocolate. 
Bread, potatoes, legumes, well-cooked cereals, especially oatmeal 
and cornmeal, farinaceous puddings with sugar and cream, cake, 
sweets, sirup, honey, sweet wines, port, porter, stout, ales, and beer. 
Malt preparations of all sorts are also useful. Sweet fruits may be 
eaten. 

To be avoided are pickles, acids, condiments, much bulk of green 
vegetables, and strong liquors. 

Diet in Acute Rheumatism 

Causation. — It has not been proved that any special articles of 
diet lead to the development of rheumatism, although indulgence 
in sweets, starchy foods, and malt liquors is sometimes held respon- 
sible for it. Poor living seems to favour the attacks, but the prevail- 
ing opinion at present is that acute articular rheumatism is an infec- 
tious disease, due to a micro-organism. 

Dietetic Treatment. — While the fever lasts and other symptoms 
are acute, such as pain and swelling of the joints, the patient should 
be put upon a fluid diet. The majority of cases do best at this time 
with an exclusive milk or bread-and-milk diet. Those patients who 
cannot take milk, however, may be allowed soups and broths fla- 
voured with vegetable extracts, chicken tea, milk toast, barley or oat- 
meal gruel, clam broth. 

Thirst is often a prominent symptom, especially if there be much 
fever, and it is advisable for the patient to drink fluid freely to assist 
in washing out the waste products from the body. Lemonade and 
slightly acid drinks of various kinds, such as dilute phosphoric acid 
or the effervescent mineral waters, are recommended. Boiled milk 
and Seltzer or Vichy may be drunk, or oatmeal or barley water 
flavoured with lemon. Alcohol should be avoided while the acute 
symptoms last, unless the complication of inflammation of the endo- 
cardium or pericardium enfeebles the heart action to such a degree 
as to make stimulation necessary. If convalescence is prolonged 



64O DIET IN DISEASE 

and anaemia is considerable, alcohol may be given as a tonic two or 
three times a day in the form of a glass of claret or Burgundy (one 
to two ounces), or diluted whisky. 

During convalescence the appetite is not usually vigorous, and it 
is not necessary to urge the taking of much food at first. The diet 
should be principally farinaceous, but not saccharine. 

Such articles may be given as rice (plain or spiced), arrowroot, 
oatmeal, cornmeal, semolina, wheaten grits, panada, milk toast, sim- 
ple unsweetened puddings, wine jelly, blancmange, and malted foods. 

The return to solid diet should be gradual, and for a long time 
the patient should abstain from eating meats as well as from pastry 
and sweets. Fagge states that no meat or fish should be allowed for 
at least a week after subsidence of the fever and acute symptoms, 
or, better, for a fortnight, and many believe that beef tea is harmful. 
Meat can undoubtedly induce a relapse. 

When convalescence becomes established, eggs, fish, oysters, and 
the white meat of broiled or roasted chicken may be given, and one 
or two such vegetables as asparagus, spinach, or stewed celery, with 
a baked apple or fresh fruit, but sweets and alcohol should long be 
withheld. 

The patient should be fed often, having one or two extra lunches 
during the day, for anaemia is apt to prevail for some time, and 
abundant nutriment is required. 

Diet in Chronic Rheumatism 

In the dietetic treatment of chronic rheumatism, especially if the 
patient is anaemic, animal food cannot be excluded, but the basis of 
the diet should be farinaceous food with a few fresh green vegeta- 
bles. Fish, eggs, and fowl may be eaten, but dark meat is not de- 
sirable. Sweets and alcoholic beverages should be omitted from the 
menu, and all foods should be plainly cooked and eaten in moderation. 

Arthritis Deformans 

Causation. — Arthritis deformans is a chronic disease in which the 
joints of the body, and particularly those of the extremities, are 
affected. The alterations in joint structures are produced mainly 
by impoverished nutrition, and the disease is especially one of ad- 
vanced life, occurring in persons in whom various evidences of senil- 
ity have begun to appear. The structural changes in the joints in- 
volve proliferation of the cellular elements of the cartilages, with 
thickening and erosion and with the production of osteophytes. In 
mild cases there is not much impairment of general health. In 
severer cases the patient is confined to the house and, on account of 
pain or immobility of the joints, is unable to take ordinary exercise. 
Digestion and nutrition suffer considerably in consequence. 



DISEASES ESPECIALLY INFLUENCED BY DIET 641 

Dietetic Treatment. — Since the disease is one of debility and im- 
poverished nutrition, it follows that a low diet is harmful and a nour- 
ishing diet, with increased frequency of meals, is desirable. James 
Stewart says : " The practice of limiting the amount of nitrogenous 
food is not to be commended. Provided there is no general or local 
contraindication, the patient should be directed to take as much 
nitrogenous food as can be digested with facility." And Garrod 
wrote : " I consider it of the utmost importance throughout the 
whole course of the disease to support the system and to allow the 
patient as nourishing a diet as he is capable of properly digesting." 
Good roast beef, beefsteak, mutton, fowl, fish, eggs, and milk may 
be eaten. 

Alcoholic beverages taken with meals in proper moderation are 
beneficial for their strengthening and tonic effect, and bitter tonics 
may be combined with them to advantage. The objection which 
exists to the use of alcohol in gout and acute rheumatism does not 
apply with such force in this disease. Malt liquors may be given, 
such as ale or stout, and it is often desirable to prescribe a good 
Burgundy, port, or sherry. If it is well borne by the stomach, cod- 
liver oil should be given in teaspoonful doses, an hour after meals, 
three times a day. It is an excellent food in this disease, and its use 
should be long continued. Other forms of fat may be used, such as 
butter, cream, or bone marrow, olive oil, etc. 

When acute exacerbations occur the quantity of food and stimu- 
lants should be reduced, but otherwise it is important that the diet 
should always be ample. 

Patients do well to try the effect of a course of treatment at the 
hot springs of Virginia, Arkansas, Mount Clemens, Michigan, or 
Banff. 

Gout 

Gout is a constitutional disease which has local manifestations 
appearing from time to time in the joints, especially the metacarpo- 
phalangeal articulation of the great toe, but it must be remembered 
that the gouty diathesis is a condition which once acquired may exist 
for years, producing many other and more serious symptoms or 
structural changes in the body than the local inflammation of one or 
more joints. 

Causation. — Gout has been defined as a condition dependent 
upon disturbed retrograde metamorphosis of the nitrogenous in- 
gredients of the food — a high-sounding phrase, which, it must be 
confessed, carries with it very little genuine explanation of the nu- 
tritive processes involved. Whatever may be the theories in regard 
to the production of an attack of acute gout, it is universally ad- 
mitted that careful regulation of the diet is the most important 
factor in its treatment. Gout and the various conditions allied to it 
are dependent upon retention in the blood or other fluids of the 



642 DIET IN DISEASE 

body of forms of waste matter which normally should be oxidised 
and completely converted into the soluble materials which are ex- 
creted in the urine. For some reason the oxidation of waste matter 
is suspended, and, as a result, a variety of intermediate products of 
imperfect solubility may be deposited in the joints or tissues of the 
body. The active manifestations of gout are due to an accumulation 
of insoluble urates in the joints. In conditions which are closely 
allied to gout, such as the uric-acid diathesis, there is a deposition 
of crystals of uric acid in some portion of the urinary tract or, in 
other conditions, deposits of insoluble cholesterin are formed from 
the bile and accumulate as gallstones in the gall bladder. 

The direct relation existing between uric acid and gout has been 
most exhaustively investigated by Garrod, and this relation may be 
briefly summarised as follows : First, the gouty diathesis is associ- 
ated with a more or less constant excess of uric acid in the blood ; 
secondly, the quantity of uric acid normally present in the urine is 
diminished by at least one half during a severe attack of gout, and 
increases beyond the normal as soon as the acute symptoms subside. 
An acute attack of gout is therefore preceded by accumulation of 
uric acid in the blood, which is a substance that in itself represents 
incomplete combustion of nitrogenous waste material in the body. 
The retention of this form of waste in considerable quantity proves 
markedly irritating to the nervous and other organs of the body. 

Sir Dyce Duckworth writes : " We perhaps come nearer a com- 
plete understanding of this matter if we regard as present in the 
gouty a peculiar incapacity for normal elaboration within the whole 
body, not merely in the liver or in one or two organs, of food, 
whereby uric acid is formed at times in excess, or is incapable of 
being duly transformed into more soluble and less noxious prod- 
ucts," and he agrees with Ralfe that the failure to complete the met- 
abolism of uric acid is dependent primarily upon disturbed inner- 
vation. 

In referring to the habit of overeating Sir Henry Thompson says 
that in early life it may cause occasional attacks of biliousness, but 
after the first half of life has been spent the remaining half may be 
affected in a different way, and " recurring attacks of gout perform 
the same duty, or nearly so, at this period of life that bilious attacks 
accomplished in youth." 

On the other hand, in persons who are subject to attacks of gout 
starvation may bring it on (Senator), and " poor man's gout " is by 
no means a disease induced by plenty. 

Sugar eaten in excess is not of itself a direct cause of gout, but 
sweets combined with certain other foods, such as special fruits 
and wines, will precipitate an attack in a gouty subject with certainty. 
According to the view of Sir Dyce Duckworth, it is the combina- 
tion of sugar with vegetable acids which is injurious. 



DISEASES ESPECIALLY INFLUENCED BY DIET 643 

Sugar, under some conditions of fermentation in the stomach 
and intestines, forms lactic acid, which is capable of splitting so as 
to produce carbon dioxide, which, according to Ralfe, forms acid 
salts of sodium and potassium from their neutral compounds. 

Lack of exercise is often assigned as a cause for gout, and with 
many persons it is true that outbreaks of gout may be intensified in 
this way ; but it is not uncommon for the disease to affect men who 
lead lives of considerable activity or who practise athletics, but who 
at the same time consume large quantities of nitrogenous food. By 
free perspiration the amount of fluid present in the blood is reduced 
and the solids become both relatively and absolutely increased, 
making it difficult or impossible for them all to become thoroughly 
oxidised. 

Symptoms. — The most distinctive symptoms of gout are the 
local joint manifestations of pain, swelling, redness, and tenderness. 
These symptoms usually occur together in an acute attack, but either 
one may occasionally be absent. Other symptoms may appear from 
time to time, such as disorders of the mucous membranes, especially 
of the stomach and bowels ; a tendency to catarrhal affections of 
the mucous membranes of the respiratory passages ; chronic end- 
arteritis ; alterations in the composition of the urine ; and various 
forms of irritation of the nervous system and the skin. 

Children who inherit the gouty diathesis are very apt to present 
some one or more of this group of symptoms, especially neuralgic 
pains, digestive disturbances, and skin diseases, which appear at an 
early age and long before the gout is fully developed with typical 
localised joint symptoms. The symptoms connected with this diath- 
esis are believed to arise from obscure alterations in the composi- 
tion of the blood which are more or less remediable by dietetic treat- 
ment. 

Preventive Treatment. — The prophylactic treatment of gout in 
those who inherit a constitutional predisposition to the disease is 
very important. From birth onward the children of gouty parents 
should be abstemious, have the diet carefully balanced so that neither 
animal nor vegetable food predominates in great excess. As the 
child grows older, confectionery and sweets in general should be 
avoided, especially with other food or at the conclusion of meals, as 
well as alcohol in every form. In youth all varieties of beer, ale, 
cider, etc., are particularly injurious. Tea and coffee, if allowed at 
all, should be taken in moderation, and some persons can often pre- 
cipitate a violent attack of gout by a single glass of champagne or 
sweet wine. 

If they are accustomed to the use of alcoholic beverages and it is 
impossible for them to go without them, those which are least injuri- 
ous are a dry white wine or old Bordeaux, but all wines containing 
sugar must be absolutely prohibited. 



644 DIET IN disease 

Cyr says : " If a glass of beer, spirits, or wine is habitually fol- 
lowed by pain in a joint or nerve it is gouty." 

Theory of Dietetic Treatment. — An important question in re- 
gard to the theory of gout is still under discussion — namely, whether 
the increased quantity of uric acid is to be attributed to overproduc- 
tion or merely to faulty elimination. It is conceivable that the fluids 
of the body, by becoming less alkaline than normal, may fail to re- 
tain the salts of uric acid in solution, and are consequently precipi- 
tated in the joints and elsewhere. The matter is of vital importance 
in the selection of the proper diet for gouty patients. If the disease 
is caused merely by imperfect oxidation of nitrogenous food, the 
indication is clearly to diminish the quantity of such food ingested 
and to promote oxidation by exercise and fresh air. If, on the other 
hand, oxidation processes are fairly normal, but the blood is in a 
morbid state in which it becomes less alkaline than normal and loses 
its solvent power upon the nitrogenous waste matters, it is possible 
that other causes may be responsible for the condition produced. 
Albumins contain both sulphur and phosphorus which are destined 
to leave the body in the form of salts of sulphuric and phosphoric 
acids respectively. If these acids fail to be wholly neutralised while 
yet in the blood they will lessen its alkalinity, and in this way over- 
indulgence in albuminous food by furnishing an excess of sulphur 
and phosphorus may diminish the alkalinity of the blood and produce 
uricsemia. This explains why the use of alkaline waters is so gener- 
ally beneficial in gout and lithaemia. Such fluids assist in regulating 
the normal alkaline reaction of the blood. This is the line of argu- 
ment which has been advanced by many physiological chemists, and 
it applies in equal force to the method of formation of renal calculi 
and gravel. The acidity of the urine is increased by a meat diet and 
reduced by a vegetable diet. With the latter it may even become 
strongly alkaline. Whether we adopt the theory of deficient oxida- 
tion or of diminished alkalinity of the blood, the indications for die- 
tetic treatment of gout are the same — namely, reduction of proteid 
food and increase of vegetable food. It does not follow that albu- 
minates must be entirely given up in all cases of gout, but they 
should be so restricted that the normal balance of the metabolism of 
the blood shall be restored. It will be found necessary for those 
who live luxurious and idle or sedentary lives to give up nitrogenous 
food absolutely while those who are accustomed to take active mus- 
cular exercise may be allowed animal food in very moderate quanti- 
ties once a day. 

Dietetic Treatment. — Although no one food is invariably inju- 
rious at all times, it is almost universally agreed that for the gouty, 
fat and nitrogenous food should be greatly restricted and saccharine 
food should be entirely prohibited. 

It may be established as a general rule that the diet of the gouty 



DISEASES ESPECIALLY INFLUENCED BY DIET 645 

should consist principally of easily digested fresh green vegetables 
and sometimes certain fruits, in addition to which a moderate quan- 
tity of lean meat (beef, lamb, and mutton) may be eaten to prevent 
the necessity of taking an excessively bulky diet, which in order to 
furnish sufficient nitrogen for the needs of the body would unduly 
tax the digestive system. Fruit is less apt to disagree if taken by 
itself, not with sugar or other food. Luff, of London, believes 
that the mineral salts of such vegetables as spinach, turnip-tops, 
Brussels sprouts, string beans, cabbage, and celery act chemically 
in preventing formation of gouty deposit in the tissues by increas- 
ing the solubility of sodium biurate and retarding the conversion 
of quadriurates into biurates. 

It is a serious mistake to prescribe any treatment for the gouty 
which tends to lower the general vitality of the system too much. 
The diet, therefore, must be so adjusted as to secure the right pro- 
portion of the different classes of foods. Atonic cases require a gen- 
erous diet with more proteids. 

Gout is often combined with excessive corpulency, and when this 
is the case no chronic disease, with the exception, perhaps, of dia- 
betes, requires more strict regulation of the diet and hygiene of the 
patient. While it is undesirable to allow animal food in large quan- 
tities in gout, it is also true that vegetables are fattening, and if the 
diet is too restricted in both these classes of foods the obese patient 
suffers from lack of nutrition, and digestion becomes still further im- 
paired in consequence. 

The theory has been held that but little fat should be eaten by 
the gouty, for it fixes oxygen which would otherwise complete the 
oxidation of albuminates, and hence it favours accumulation of pro- 
teid waste products. On the other hand, it has been show T n that the 
accumulation of uric acid is not due to lessened oxidation, but that 
it is increased by proteid metabolism, and its elimination by the kid- 
neys is actually promoted by fats. Clinically, however, it is found 
best to control the use both of albumins and fats. 

Sugars and gelatinous material, like fats, all tend to retard the 
complete combustion of proteid food, and the latter therefore remains 
in an imperfectly oxidised condition which may give rise to uricse- 
mia. The combination of the latter classes of foods, therefore, is 
particularly injurious in gout. On the other hand, Ebstein favours 
the use of fat in moderation, on the ground that it appeases the 
appetite and makes the consumption of a large quantity of carbo- 
hydrates unnecessary. If fat is allowed at all in the diet, it is best 
to give it in very small amount ; otherwise it interferes with the 
local digestion in the stomach and tends to aggravate the dys- 
pepsia which is so common in gouty subjects. It will be better 
borne in those cases which are not complicated by a tendency to 
obesity. 



646 DIET IN DISEASE 

In the dietetic management of gout in robust subjects it is of 
quite as much importance to reduce the quantity of food consumed 
as to restrict the variety. 

Robust gouty patients must be made to restrain a too vigorous 
appetite, and especially the eating of all sorts of foods between 
meals, for, as Balfour says (The Senile Heart), " there is nothing 
so destructive of gastric comfort as the continual pecking induced 
by gouty bulimia." 

They should never be allowed to eat to complete satiety at meals, 
and all rich sauces, pastry, and strong condiments and fried food 
should be avoided. The majority of gouty patients have been in the 
habit for a long time of eating too much meat, and some of them 
of partaking too freely of carbohydrates. Overeating is almost as 
bad for patients as drinking too much. " Gout is evidence of an 
overfed, overworked, and consequently clogged machine " (Osier). 
As Bence Jones says : " It is best to allow a minimum of albuminous 
food to produce the least amount of uric acid and a minimum of car- 
bohydrates, in order to give the uric acid formed opportunity to be 
oxidised as much as possible.'' 

When an acute exacerbation of gout occurs it is necessary to 
curtail all variety in diet, and put the patient upon light farinaceous 
food with abundant diluents, alkaline waters, weak tea. Gruels of 
sago, arrowroot, or barley may be given, with bread or toast. When 
the fever subsides and the acute symptoms abate, bouillon, clam 
juice, simple broths made of lean mutton or chicken with rice, may 
be allowed. Later, a little whitefish or breast of chicken. Meat 
should be given only when absolutely necessary for nourish- 
ment, for, as Garrod says of it, " everything beyond what is 
absolutely required for the nourishment of the body only feeds the 
disease." 

Sir Dyce Duckworth's treatment of the acute disease is briefly as 
follows : He recommends such substances as rice, bread, arrowroot, 
sago, tapioca pudding, and semolina. He allows milk, weak tea, and 
infusion of cocoa nibs. Later, chicken broth may be given, fol- 
lowed by fish and a mealy roasted potato. No meat should be given 
until all acute symptoms are over, and then it should be allowed 
but once a day. Elderly persons may have a little dilute whisky or 
brandy, not to exceed two ounces per diem. He also favours the use 
of hot water, as in the treatment of dyspepsia, but discountenances 
the eating of fruits, especially with sugars. 

When the acute attack subsides and chronic gout supervenes 
Garrod replaces the farinaceous diet gradually by fruit, fish, fowl, 
and finally by meat, but any dishes containing free acids or sweets 
are liable to cause a relapse. 



DISEASES ESPECIALLY INFLUENCED BY DIET 647 



DIET FOR THE GOUTY DIATHESIS AND CHRONIC GOUT 

In the following dietary a liberal variety of foods will be found, 
some of which may be selected and changed from time to time ac- 
cording to need in the intervals between the exacerbations or in 
chronic gout. Should an acute attack occur at any time in the 
course of the disease, the diet must be at once restricted, as described 
above. The number of dishes allowed at any one meal should be 
few. In dealing with any case of chronic gout for the first time it 
is injudicious to make radical changes in the diet too suddenly. 

Soups. — Soup should be free from all fat, and it is better made 
of vegetables than meat, and purees of potatoes, celery, etc., may be 
recommended. If the taste of meat is desired, as suggested by 
Yeo, it is best imparted to the soup by one of the meat extracts 
which contain simply the highly flavoured extractive matter without 
contributing to the bulk of proteid food. A teaspoonful or two of 
Valentine's meat juice or Liebig's extract of meat in a half pint of 
vegetable soup accomplishes this result. 

Milk. — Alilk wholly disagrees with some gouty persons, but in 
those who digest it well, if it be not too rich in fat or if it is taken 
skimmed or diluted, it forms an excellent food. Many are, however, 
opposed to its use in any form^ even when rendered alkaline by the 
admixture of alkaline waters or a few grains of bicarbonate of so- 
dium. Yeo gives a small salt-spoonful each of potassium bicarbonate 
and common salt in a breakfast-cupful of hot milk and water. Oth- 
ers give it with warm w r ater. The attempt has been made to place 
gouty patients upon an exclusive milk diet. This sometimes, but not 
often, aids those who are robust and young, but it is injurious to 
older patients. 

Cheese, being a concentrated, proteid food, should not be eaten. 

Eggs. — Garrod allows eggs and bacon for breakfast, and Ralfe 
recommends an occasional " savoury omelet." Eggs cooked with 
milk and custard puddings (unsweetened except with saccharin) 
may sometimes prove harmless, but Senator is opposed to them on 
account of the fat and lecithin which they contain. 

Shellfish and Crustaceans. — The soft part of oysters and clams 
may be eaten, but crabs, lobsters, and shrimps may not be allowed, 
least of all in salads. 

Fish. — Some writers maintain that fish should constitute the 
chief nitrogenous food, while others prescribe it very moderately, if 
at all. 

Broiled or boiled fish, such as bluefish, whitefish, bass, shad, are 
permissible occasionally for variety, but fish having firm flesh and 
those which contain considerable fat are not good. Salmon, mack- 
erel, halibut, codfish, should therefore be avoided, although Garrod 
43 



648 DIET IN DISEASE 

allows salmon served with salt and Cayenne, but without sauce. 
Rich sauces must not be eaten with fish or salads. In lieu of them, 
a simple dressing of an infusion of aromatic herbs and pepper, or a 
plain bread sauce, may be employed. 

Smoked and pickled fish are forbidden. Fish roe, such as shad 
roe and caviare, is admissible. 

Meats. — Meat cannot be prohibited entirely for months at a time 
in chronic gout, especially for a middle-aged man, although the 
young may thrive better without it. It should be only eaten once a 
day in any case, and roasting or broiling is the best form of cooking 
it. Twice-cooked meats should not be eaten. Beef, lamb, and poul- 
try may be allowed sparingly. Generally speaking, white meat is 
better than dark meat. Veal, pork, fat bacon and ham, game, and 
dried, smoked, pickled, or salted meats must all be forbidden. Only 
one kind of meat should be eaten at a meal. 

Fats. — Fats should be used sparingly, and all food fried or cooked 
in grease must be forbidden. Fat meats and fat fish are to be 
avoided. A little well-cooked bacon may occasionally be eaten, and 
butter may be taken only in moderation. The objection to the use 
of fats and oils is that, unless the general nutrition is very poor, they 
interfere in gouty subjects with complete oxidation of proteid 
elements. 

Farinaceous Food. — Farinaceous food is allowable, and in the 
acute stage of gout it should constitute the main diet. Bread (not 
fresh), rice, sago, tapioca, oatmeal, cracked wheat, may all be eaten. 
Pastry, cake, hot rolls, hominy, griddle cakes, preserves, and confec- 
tionery of all kinds are forbidden. 

Sugar. — Sugar has not proved to be always harmful to the gouty, 
but eaten with a mixed diet, especially with fruits or drunk with 
wines, it undergoes fermentation processes which are at once dis- 
tinctly harmful. It is generally admitted that carbohydrates eaten 
in excess with other food are more injurious than fats in excess. 

Sweets, jams, and jellies of all kinds are forbidden. When sugar 
positively disagrees, a little glycerin or, better, saccharin or diabetin 
(levulose) may be substituted for it. 

Vegetables. — Of vegetables, although a great variety are eaten, 
there are a few which are prohibited on account of the fact that they 
contain oxalic acid, which is closely allied to uric acid, and which 
produces oxaluria. These are sorrel, radishes, asparagus, rhubarb, 
tomatoes, and spinach. The two latter are allowed by some au- 
thorities, however. Beets are forbidden. Vegetables, such as cab- 
bage, onions, old peas, beans, and corn, if they occasion flatulence, 
must be eschewed. The following may be eaten : French peas 
(petit pois) and young French beans, string beans, celery, young 
tender green corn, carrots (very moderately), turnips, parsnips, well- 
baked and mealy potatoes (except sweet potatoes) sparingly, cu- 



DISEASES ESPECIALLY INFLUENCED BY DIET 649 

cumbers, broccoli, beet tops, cauliflower, celery plant, eggplant, 
okra, artichokes. Salads, provided they are not dressed with much 
oil, are allowable. Vegetables which act injuriously on account of 
their acids are made still more harmful by being cooked with sugar. 

Fruits. — Some writers allow fruits of almost every kind, both 
raw and cooked, but Sir Dyce Duckworth and many authorities de- 
clare that fruits in general are harmful. Sir Andrew Clarke forbade 
their use in toto. If they produce no dyspepsia, and are ripe and 
fresh, a few fruits may be eaten, such as stewed pears, or apples 
stewed, baked, or roasted ; but all those fruits which contain large 
quantities of sugar, such as grapes, figs, bananas, prunes, etc., must 
be forbidden, as also acid fruits, especially strawberries. No fruits 
cooked with sugar can be allowed. Melons are forbidden. Garrod 
expressly forbids all stone-bearing fruits, and says that subacid 
fruits furnish alkaline salts that split up in the blood and reappear 
in the urine, chiefly as potassium carbonate, and stimulate the kid- 
neys. Melons are usually the least hurtful of fruits. 

Fothergill wrote : " The potash in the strawberry renders its juice 
a desirable drink for the gouty and for strumous children," but there 
are many patients who cannot eat a half dozen strawberries without 
an exacerbation of inflammation in a gouty joint. 

If any fruit is eaten it should not be in connection with other 
food or with sugar. Hence all candied fruits are proscribed. Nuts 
are forbidden. 

Pickles, vinegar, spices, strong condiments, salted foods, mush- 
rooms, and truffles must all be forbidden. 

Eating between meals and at irregular intervals is injurious. 
Fresh air and exercise are often more needed than extra luncheons 
of bouillon, broths, wines, etc. 

Ralfe gives the following menu for breakfast and lunch : 

Breakfast. — A poached egg, bacon, or fresh fish, tea (coffee and 
cocoa disagree) without milk or sugar. 

Light Lunch. — A clear soup, vermicelli or julienne, sandwiches, 
cold meat with salad. 

Dinner is to be eaten not too late, and fully three hours before 
retiring. 

Cantani's treatment of gout is based on the belief that all sub- 
stances should be withheld from the diet which retard the oxidation 
of nitrogenous food or lessen alkalinity of the blood. He there- 
fore prohibits all fatty, farinaceous and saccharine food, including 
bread and potatoes, sweet fruits, etc., but allows fish, eggs, broth, 
and fresh green vegetables to be eaten. Especially to be avoided 
are milk, cheese, all acid foods, pickles, sweets, pungent condiments, 
bread, rice, potatoes, all farinaceous foods, and coffee. 

Sir Dyce Duckworth gives the following excellent menu for 
goutiness or chronic gout in Allbutt's System of Medicine : 



650 DIET IN DISEASE 

" Six or eight ounces of hot or cold water may be taken half an 
hour before breakfast. Breakfast should consist of one or two 
ounces of well-toasted stale bread without butter, grilled whitefish, 
grilled mutton chop or beefsteak, or cold chicken, game, beef, 
tongue, or lean ham. One or two small cups of tea or coffee, with a 
little skimmed milk and without sugar may be taken. Saccharin 
may be used as a sweet flavouring agent, but is commonly disliked. 
Six ounces of bouillon or clear soup may be taken by weakly pa- 
tients between breakfast and luncheon, and a gluten or almond bis- 
cuit with it. For luncheon order cold meat or a poached tgg with 
spinach or lettuce, or other green vegetable, as watercress and mus- 
tard and cress, or a small omelet. Crust of bread or hard biscuit 
in small amount is allowable and a small quantity of fresh butter. A 
glass of good Bordeaux or Moselle wine (dry) may be taken with as 
much water. A cup of tea with a little skimmed milk and a rusk or 
gluten biscuit may be taken in the afternoon. For dinner no soup 
is to be taken, as a rule, but occasionally about eight ounces of a 
thin consomme may be allowed, then a little grilled or boiled fish, 
without starchy or fatty sauces, but flavoured sometimes with an- 
chovy or some other sauce, oysters, or caviare, a little grilled or 
roasted meat, mutton, game, or fowl, with a small proportion of fat, 
green vegetables, no potatoes, and some stewed fruit flavoured 
with saccharin or made less tart by the addition of half a teaspoon- 
ful of Rochelle salt. Two glasses of claret or of a dry Moselle di- 
luted with water are allowable. Later in the evening a cup of hot 
weak tea, without milk, or as much hot water should be taken." 

BEVERAGES 

Water. — It has been already stated that to favour the washing 
of waste matter from the system it is desirable to drink considerable 
quantities of fluid, and gouty people who are corpulent usually per- 
spire with freedom; their urine therefore becomes concentrated, 
and there is a tendency to the precipitation of uric acid, urates, and 
oxalate of lime. It must be observed that the presence of uric acid 
in the urine does not always indicate an excess of that acid, and it 
may happen that the urine is too concentrated or otherwise altered 
to hold it in solution, and hence precipitation results. An excess of 
acid phosphate may combine with the sodium and potassium which 
are necessary to hold the uric acid in solution in the form of urates, 
and it is deposited in insoluble crystals. Copious draughts of hot 
water at bedtime or taken on rising in the morning are often pre- 
scribed, but it is doubtful whether the temperature of the water 
makes any difference in the desired result so long as plenty of fluic 
is taken. 

Fluid should be drunk half an hour before meals, when the stom- 
ach is empty. Besides serving to cleanse the mucous membrane oi 



DISEASES ESPECIALLY INFLUENCED BY DIET 65 1 

the alimentary canal, the diuretic action of water will be greater when 
absorbed at such times. 

Sir Dyce Duckworth holds somewhat different views in regard to 
water drinking, although he does not make clear his reasons for so 
doing. He says : " I feel sure that Sydenham was right in condemn- 
ing water drinking for the gouty. ' Water alone is bad and danger- 
ous, as I know from personal experience. When taken as the regu- 
lar drink from youth upward it is beneficial/ ,: He prefers to allow 
a moderate quantity of wine — from four to six ounces of good sound 
Bordeaux, and adds : " The least excess is harmful, but a little good 
wine is better for most gouty persons than water drinking, espe- 
cially after middle life." This, of course, was written for English- 
men in the upper classes, whose ordinary consumption of wine is 
greater than that of Americans in the same social position. Much 
depends upon one's previous habits of life, and in this country ex- 
amples of gout may not rarely be found among patients who have 
never been in the habit of drinking alcoholic beverages daily, and 
such persons do best to abstain from them entirely. 

Tea, Coffee, etc. — Tea and coffee are admissible among bever- 
ages for the gouty, and it will be found that they are less likely to 
cause dyspepsia if taken quite weak without sugar. A quarter of a 
grain of saccharin may be added instead. Senator forbids tea and 
coffee, and prescribes " acorn coffee." Infusion of cocoa nibs is less 
to be recommended on account of the excessive fat which it holds. 
Esbach states that he has found oxalic acid in it also, amounting 
sometimes to 0.4 per cent. Chocolate is forbidden. 

Patients who are still able to lead active outdoor lives may 
drink more alcohol than those of sedentary habits, without aggravat- 
ing their symptoms. In general the quantity consumed is as im- 
portant as the quality, and it should be definitely prescribed and 
kept within bounds. 

Alcoholic Drinks. — With regard to the use of alcoholic bever- 
ages it is their acid and saccharine ingredients rather than the alcohol 
itself which disagree. Strong liquors, diluted, may not be injurious, 
but nothing is worse than rich sweet wines and malt liquors. 

It is, however, true that alcohol in all forms lessens the elimina- 
tion of tissue waste, and decreases the volume of urea and uric acid 
excreted. According to Pfeiffer, both beer and wine may lessen this 
volume by one half ; on the following day it is increased, and subse- 
quently diminished again. The longer wines have been fermented, 
or the more complete the conversion of the sugar to alcohol, the 
less hurtful they become to the gouty. 

While free perspiration exists in warm weather, and free diuresis 
as well, alcoholic drinks of all kinds are less harmful. Whatever 
form of alcohol is taken, it should be drunk to the exclusion of all 
others, for mixtures are particularly bad. 



652 DIET IN DISEASE 

Strong beer, ales, porter, stout, all malt extracts, and sweet cider 
must be absolutely prohibited. Sir Henry Thompson and Germain 
See regard cider as beneficial as a solvent of uric acid, but by oth- 
ers it is looked upon as injurious on account of the malate of po- 
tassium which it contains, and which it is claimed favours the for- 
mation of uric acid (Yeo). Undoubtedly the alcoholic drinks which 
are best tolerated by the gouty are good French Cognac or old 
Scotch whisky, well diluted with water, Apollinaris, or soda water. 
Scotch whisky is by many found to agree better than any other 
variety. Weak brandy and soda may be substituted, or unsweet- 
ened Plymouth gin. It is the part of wisdom to abstain entirely from 
alcohol. Very many persons are so habituated to its use that they 
are unwilling to abandon it, and a compromise must be effected. 
It is easier for them to give up certain foods than drink. There are 
some wines which should be absolutely prohibited, among them 
all which are re-enforced by, or which contain, a large proportion 
of saccharine material. Strong port, sherry, champagne, Madeira, 
Canary, claret, and Burgundy are comprised in this list. 

Port wine has even acquired the reputation of being a primary 
factor in producing gout, when a hereditary diathesis does not exist. 
It is an incompletely fermented wine to which alcohol has been 
added for preservation, and all wines of this class are the worst 
forms of alcohol for the gouty. Garrod says that exceptionally a 
sound sherry, Amontillado or Manzanilla, may be prescribed. There 
are patients, too, who maintain that they do better with port as a 
daily beverage than with any other form of wine, but their example 
would be a very unsafe one to follow, and their experience is due to 
constitutional idiosyncrasy. 

Duckworth says : " Rhenish wines are acid and harmful ; those of 
the Moselle district are, however, less acid, and rather better borne. 
Australian, Californian, Hungarian, Greek, and other Mediterranean 
wines are too strong, and after a time generally disagree." 

An absolutely dry champagne may sometimes be permitted, or 
very dilute and weak pure claret. The stronger clarets containing 
more tannin, and all wines with much free acid, are injurious. 
Among the light wines, several may be permitted in moderation, 
but they should be diluted with an alkaline water in order to com- 
pletely neutralise any acidity. 

Such wines should be either long bottled or drunk from the 
cask, for newly bottled wines are more injurious. 

The best Bordeaux and lightest Hungarian wines, light hock and 
a still Moselle, such as Zeltinger, may be drunk, for these wines are 
quite thoroughly fermented, and therefore contain no sugar or free 
acid, though they have salts, such as cream of tartar. These wines 
should only be allowed in extreme moderation, not over half a pint 
in a day. 



DISEASES ESPECIALLY INFLUENCED BY DIET 653 

Yeo says : " The more distinguished the diuretic effect of the 
wine, the better, as a rule, will it agree with the gouty." 

Ralfe's practice is to allow no wine of any sort with dinner, but 
afterwards two claret-glassfuls of some light wine are permitted ; 
and he says that a tablespoonful of brandy in half a tumblerful of 
water before meals increases the secretion of gastric juice. If the 
patient is weak, or suffers from insomnia, he gives brandy or whisky 
at bedtime in some effervescing water. 

He states that in his experience patients who have been long 
habituated to the daily use of port, sherry, or ale, often become 
worse when a sudden change is made to claret or hock. In such 
cases he advises changing gradually by substituting at first a drier 
port or sherry. 

Usually such red wines as St. Julien and St. Estephe are prefer- 
able to the higher class, such as Lafitte or La Rose. 

Different persons show peculiar idiosyncrasies in regard to the 
gout-producing influence of certain wines. Some will always have 
gouty inflammation set up within a few hours in a particular joint by 
one form of liquor or wine and not by others. 

Saline Waters. — Alkaline and saline mineral waters have a well- 
deserved reputation for benefiting gout. Many persons, especially 
obese gouty subjects, are helped by taking one or two " courses " of 
treatment a year for two or three successive years at Carlsbad, in 
Bohemia, or elsewhere. Carlsbad water may be drunk at home, 
four or five ounces being taken on rising in the morning, or an 
equivalent of the evaporated salts — chiefly sodium sulphate. 

The water of the Kreuzbrunnen at Marienbad has essentially the 
same composition with that of Carlsbad, and contains even more 
sodium sulphate. Elderly persons may be injured by a too vigorous 
use of these salines, and they should take only milder alkaline waters 
containing less sodium. 

The German Fachingen water has proved very serviceable. It 
contains 3.5 per cent of bicarbonate of sodium and 6 per cent of 
bicarbonate of lime. 

Vichy is good for strong patients, but not for the feeble or 
anaemic. It also contains considerable sodium bicarbonate, and the 
Vals water has more sodium carbonate than many alkaline waters. 
These waters favour the elimination of uric acid as a salt rather than 
in the free state. 

Saratoga alkaline water is among the best in this country for 
gouty patients. It contains carbon dioxide, sodium and alkaline 
carbonates, and chlorides. The waters of the St. Clair Spring in 
Michigan, and St. Catherine Spring in Ontario, are good alkaline 
salines for gout. Many lithia waters are also recommended, but 
they contain little lithium. Apollinaris and Johannis water are 
good. All beverages drunk by the gouty should be well diluted, and 



654 DIET IN DISEASE 

mildly alkaline mineral waters are especially valuable for this pur- 
pose. 

Aids to Dietetic Treatment. — The individual peculiarities of 
digestion should be carefully studied in each case by the physician, 
and the patient must be very thoroughly examined in regard to 
the minutiae of all his hygienic and dietetic habits. Meals should 
be taken at stipulated hours — the breakfast on rising, dinner not 
later than three o'clock, when practicable, and late suppers should 
be avoided. Between the acute attacks it is absolutely necessary to 
maintain digestion in a normal condition. The bowels must be kept 
open, and the condition of the skin should be actively maintained 
by cold bathing and friction. Exercise should be taken in the open 
air. The urine should be frequently examined, with especial refer- 
ence to the hour of the day at which it is passed and the relation 
which its composition bears to the food eaten. 

Diabetes Mellitus 

Nature of the Disease. — Diabetes mellitus is a disease charac- 
terised by the passage of a large quantity of urine containing grape 
sugar or glucose and usually of high specific gravity — 1.035 or 
more — excessive thirst, and sometimes exaggerated or perverted 
appetite ; progressive emaciation ; muscular weakness and langour. 
The disease runs a chronic course, and the majority of cases ter- 
minate fatally in from two to four years. Death may result from 
inanition or from " diabetic coma " or other causes. The knowledge 
of the disease has been very largely obtained from experimentation 
upon the lower animals, in which diabetes can be artificially pro- 
duced. The treatment is almost entirely dietetic and hygienic, for 
as yet no medicinal remedy has been found which is curative, and 
very few have been discovered which are even palliative in any num- 
ber of cases. Diabetes is therefore essentially a dietetic disease, for 
although not usually caused by errors in diet it may be exception- 
ally so produced, and most cases are more or less benefited by 
dietetic treatment, while some may undoubtedly be cured by it. 

Diabetes was described more than a century ago ; and Rollo in- 
augurated the dietetic treatment by withholding vegetable food. In 
1838 Gmelin and Tiedemann established the existence of the relation 
between the digestion of carbohydrates and the formation of sugar. 
In 1848 the eminent physiologist Claude Bernard began elaborate 
researches which first threw definite light upon the relations of the 
liver to the consumption of sugar and the formation of glycogen, and 
since that day a number of physiologists and clinicians in many coun- 
tries have contributed extensively to the knowledge of the disease. 
Notwithstanding this fact, however, the true cause of this affection is 
still obscure, and aside from dietetic treatment but little advance can 



DISEASES ESPECIALLY INFLUENCED BY DIET 655 

be claimed in regard to the controlling influence of medicine. The 
method of production and elimination of the sugar and the influ- 
ence of the disease upon general nutrition is understood, but its real 
exciting cause and the fundamental reason for the interesting de- 
parture from the normal metabolism of starchy foods which is its 
basis is still unknown. 

Frequency. — Diabetes is not a very rare disease, and a few cases 
occur from time to time in the experience of almost every general 
practitioner. It is reputed to be of more common occurrence to- 
day than it was fifty years ago, but this fact is possibly due to 
the much more careful and frequent urinary analyses which are 
made as a matter of routine by all physicians, that often reveal a 
latent diabetic condition which might otherwise have been over- 
looked. In regard to those cases which are of neurotic origin, the 
general increase in the proportion of diseases of the nervous system 
which has been observed in the United States must be taken into 
consideration. Diabetes may occur alone or in association with a 
variety of diseases, particularly those of the liver, pancreas, lungs, 
and nervous system. 

Causation. — The influence of heredity can be traced as a factor 
in about one third of all cases. The disease may occur in any cli- 
mate and in any age with either sex, but it is commonest in males 
in the proportion of three to one. In females it occurs oftenest be- 
tween twenty and forty years ; in males, between thirty and forty- 
five years. It is somewhat more common among the wealthy than 
the poor because of sedentary habits combined with overindulgence 
in eating. The obese, particularly those who have much omental 
fat, are more liable to diabetes than are thin persons who are more 
active. 

Cantani has observed the unusual prevalence of diabetes in south- 
ern Italy, where carbohydrates are so extensively used, and he be- 
lieves that the liver is exhausted by metabolising such food, while at 
the same time it is weakened by failure to receive proteids. This 
view will hardly withstand the criticism that in many other coun- 
tries the natives have lived for generations upon carbohydrates with- 
out developing diabetes. 

Among the various determining causes of the disease have been 
reported blows and shocks affecting particularly the nervous sys- 
tem, injuries to the back of the head and blows over the liver, as 
well as general concussion, such as that produced in railway acci- 
dents ; exposure to cold, wet, and fatigue ; convalescence from 
fevers; emotional strain, worry, mental fatigue, and anxiety. Tu- 
mours and haemorrhage at the base of the brain and circumscribed 
lesions of the floor of the fourth ventricle have been known to oc- 
casion the disease. A number of cases have been associated with 
disease of the pancreas, as stated below (p. 660). 



656 DIET IN DISEASE 

Overindulgence in Food. — There is some doubt whether any one 
article of diet can determine an attack of diabetes, although inordi- 
nate eating of candy, preserves, raisins, fruit, confections, etc., may 
occasionally cause temporary glycosuria. 

Bernard claimed that taking excess of starch into an empty stom- 
ach caused transient glycosuria in animals, but this observation has 
not been uniformly confirmed in man. 

Fowler wrote some time ago : " I have been in the habit of sup- 
plying my classes with saccharine urine simply by taking about four 
ounces of dried dates or about a tablespoonful of pulverised glucose 
upon a fasting stomach." 

According to Harley, temporary glycosuria may be induced by 
eating asparagus. 

Rich food of either an animal or vegetable nature keeps the 
liver constantly overtaxed, and unrestrained indulgence in sweets, 
new wines, and sweet fruits is said to excite diabetes. Sugar may 
be present in the urine in the proportion of from five to ten parts per 
thousand, but so long as its occurrence in this manner is of brief 
duration, and so long as it can be immediately traced to indiscre- 
tion in the abuse of saccharine foods, it is of little practical signifi- 
cance. It has been claimed that continued eating of predigested 
starchy foods containing too much glucose may result in the pro- 
duction of diabetes. 

In transient glycosuria the ingestion of excess of cane sugar 
does not, according to Worm-Muller and others, produce glucose in 
the urine, but saccharose, and he attributes diabetes to overfermen- 
tation on the part of the liver. 

In diabetes lactose reappears in the urine as glucose, but under 
normal conditions if eaten in excess it causes a transient lactosuria. 



RELATION TO GOUT AND OTHER DISEASES 

The frequent association of gout and diabetes has long been ob- 
served, and in " gouty glycosuria " (Brunton) comparison is made 
between the chronic hyperemia of the diabetic liver and the acute 
hyperemia of the gouty joints. 

Occasionally persons past fifty years of age who are gouty may 
present the symptom of glycosuria without other accompanying 
manifestations of diabetes, such as emaciation and debility. This 
symptom may persist for a number of years and end in recovery, or 
the patient may die of some intercurrent disease in no way con- 
nected with diabetes. 

In a long series of cases of diabetes reported by Ord, gout oc- 
curred in over one third, and in some there was arthritis deformans. 
In these cases not only does the urine contain sugar in excess, but 
the urea and uric acid are largely increased. It is interesting to 



DISEASES ESPECIALLY INFLUENCED BY DIET 657 

remark in this connection that similar dietetic treatment benefits 
gouty, obese, and diabetic patients, for they live best upon a nitrog- 
enous diet with alkalies. The occurrence of an excess of uric acid 
in the urine (uricaemia) is often a forerunner of diabetes (Coignard, 
Comillon). Diabetes is also often associated with neuralgia, phthisis, 
hepatic engorgement, and congestion. There is no one form of dis- 
ease of the liver in which diabetes is uniformly or frequently asso- 
ciated. In about one third of the cases a history is obtainable of 
mental strain or overwork, and in about one third there is a history 
of alcoholism. 

PHYSIOLOGICAL EXPERIMENTS 

In order to understand fully the dietetic treatment of diabetes, it 
will be necessary to discuss somewhat at length certain physiological 
experiments and theoretical causes in relation to aetiology. These 
topics will be found to throw some light upon the relations of diet 
to the symptoms. The experiments of Claude Bernard above al- 
luded to were made to determine where the sugar which has been 
ingested by an animal is destroyed. He was the first to accurately 
determine the amount of sugar normally present in the blood. Ac- 
cording to his estimate, when this quantity does not exceed three 
parts in one thousand, the limits of health are not surpassed, and 
sugar does not appear in the urine, as it promptly does when the 
proportion is increased. 

He fed animals heavily upon sugar, killed them, and examined 
the blood from various blood vessels. In this manner he ascertained 
that a good deal of sugar is destroyed by the passage of the blood 
through the lungs, but he also found it to be carried by the hepatic 
vein, whjle the portal vein contained a trace only. He demonstrated 
that the liver, excised from the body and washed free of all blood 
by a stream of water injected through the portal vein, would, after 
standing for a few minutes, still yield sugar. He thus proved that 
the liver is capable of forming sugar by some process which is con- 
tinued independently of its blood supply. He next searched for the 
source of the sugar formed by the liver, and discovered the sub- 
stance, to which he gave the name of " glycogen." Glycogen, or 
animal starch, is a normal ingredient of the liver cells, in which it is 
stored in the form of amorphous granules around their nuclei. When 
treated by diastatic ferments or boiled with dilute mineral acids, it 
is converted into a grape sugar or glucose. Hensen, of Kiel, dis- 
covered glycogen independently of Bernard and at nearly the same 
time. This substance, which is isomeric with starch, occurs in the 
skeletal muscles as well. 

Bernard also found that the quantity of sugar which he could 
collect from the hepatic vein at any time did not increase when the 
animal was fed upon a large amount of sugar ; this circumstance led 



658 DIET IN DISEASE 

him to argue that the liver arrests the sugar ingested on its way to 
the general circulation, and thus acts as a regulator of the amount 
of sugar contained in the blood. 

Man takes his food at comparatively infrequent intervals, and it 
is important that the energy derived from the ingestion of a large 
meal of carbohydrates should not be immediately expended, but 
should be stored in some form which will enable it to be gradually 
used in the intervals between digestion of meals, and in any emer- 
gency when food is withheld for a longer time than usual. The liver 
affords this means of storing a considerable amount of energy by 
converting the sugar — brought to it in the portal system which has 
been absorbed from the intestinal wall — into glycogen, a temporary 
product which is stored and held back in the liver cells, but which 
can be readily paid out in small quantities from time to time into 
the hepatic blood as it leaves the liver. In this manner an excess 
of sugar ingested or an excess of sugar derived from the digestion 
of starchy food is normally kept from immediately entering the 
circulation, and its use is economised by holding it back until it is 
required for force production. The ultimate destination of the 
sugar reformed from the glycogen of the liver is that it is consumed 
either in the capillaries or intercellular spaces or in the muscular 
and other tissues of the body by obscure ultimate processes of nutri- 
tion, which result in its splitting up into carbonic acid and water 
with the evolution of heat. In support of this view Claude Bernard 
proved that there was less sugar in systemic venous blood than in 
arterial blood. 

Bernard extracted with glycerin a diastatic ferment from the 
liver and blood, which he supposed had the function of converting 
the glycogen into glucose ; this action he called the " glycogenic " 
function of the liver. The sugar absorbed from the intestines and 
arrested in the liver he supposed to be there converted into glycogen 
by the glycogenic ferment. Glycogen is also formed from peptones. 
Foster says that glycogen may be accumulated in the liver upon a 
mixed diet, and that it may be in part formed by dehydration of 
sugar derived from metabolism of proteid food. It is a fact that 
when diabetes is once established, the elimination of sugar in the 
urine will sometimes continue in both man and animals kept upon 
an exclusive nitrogenous diet. 

The foregoing experiments, verified by many physiologists, have 
given rise to three principal theories regarding the origin of glyco- 
suria, which are as follows : 

1. It is due to impaired glycogenic function, and the sugar 
taken as a food is at once passed into the general circulation 
unaltered. 

2. It is due to increased glycogenic function ; there is an over- 
production of sugar from the glycogen, the latter being derived both 



DISEASES ESPECIALLY INFLUENCED BY DIET 659 

from sugar and peptones, and the newly formed sugar is swept into 
the blood. 

3. The conditions of absorption of carbohydrates and of the func- 
tional activity of the liver may remain normal, and yet the final com- 
bustion of sugar by the tissues or its assimilation by them may be 
imperfect and lead to its accumulation in the blood and subsequent 
appearance in the urine. 

The three conditions mentioned above imply either diminished 
activity of the liver, increased activity of the liver, or a normal liver, 
the fault being in other tissues of the body. 

Either one will give rise to the presence of an abnormal amount 
of sugar in the blood (glycohaemia), which is excreted by the kid- 
neys (glycosuria). To aid in substantiating these theories, it should 
be proved : (a) That there is a definite relation between the quantity 
of sugar that leaves the liver and the quantity of glycogen remain- 
ing in the liver, (b) That the " glycogenic ferment " resembles 
diastase, (c) That the glucose passing through the hepatic vein is 
identical with the sugar which can be formed from starch by fer- 
mentation, (d) That there is a definite relation between the quan- 
tity of hydrocarbons (and peptones) entering the liver and the 
quantities of glycogen and glucose subsequently obtained. The ex- 
periments of Bernard have been in the main confirmed by other 
physiologists, but there is exception taken to some of them, and his 
theories are not universally accepted. 

It is probable that in the majority of cases the primary difficulty 
is to be found in altered metabolism in the liver. 

Pavy strongly favoured the view that diabetes is due to a faulty 
action of the liver in not preventing the sugar which is brought to it 
by the portal vein from reaching the general circulation. 

The essential difference between the theories of Bernard and 
Pavy in regard to the glycogenic function of the liver concerns 
merely the final destination of the glycogen. Both agree as to the 
primary conversion of sugar from the portal vein into glycogen, but 
while Bernard believed that the glycogen is reformed into glucose 
and consumed in the tissues, Pavy held that the normal use of glyco- 
gen is in the formation of fat. 

Pavy believed that a small amount of sugar may be absorbed by 
the lacteals during the digestion of sugars or starches passing 
through the thoracic duct directly into the venous circulation with- 
out entering the liver. This he considered a normal condition. It, 
however, requires the use of far more delicate tests than those com- 
monly employed in clinical work to detect the minute traces of sugar 
in the urine which Pavy claimed are normally present. 

Pavy has propounded another ingenious theory to account in 
part for diabetes, even though other theories be not wholly aban- 
doned. It is that the intestinal epithelium of the villi ordinarily ex- 



660 DIET IN DISEASE 

erts a sort of glandular control over the sugar absorbed from the 
bowel, and converts it into glycogen and fat as it reaches the blood. 
Failure to perform this function results in the production of glyco- 
suria. This failure, Pavy holds, is due primarily to faulty nerve 
action affecting the calibre of the arterioles and capillaries with hy- 
peroxidation, which favours the too rapid conversion of carbohy- 
drates into glucose, causing glycosuria. This theory has been some- 
what severely criticised by Paten, and is opposed to Seegen's views, 
but it does not exclude belief in the storage of carbohydrates as gly- 
cogen in the liver — it is merely accessory to it. 

If the liver of an animal be rapidly excised and cut into small 
fragments to prevent further fermentation, it will be found on anal- 
ysis to contain sugar in a small proportion which varies, according 
to different observers, between 0.2 and 0.6 of 1 per cent (Bernard and 
Seegen) ; hence but little sugar is to be found in the liver during 
life, or immediately after death, and it has been suggested by Flint 
that whatever sugar may be found is immediately washed out by the 
hepatic blood stream. If the excised liver be not boiled, but be 
allowed to remain at the body temperature for some minutes, or if 
the portal circulation be suddenly cut off while the liver remains in 
the body, it is found that the formation of sugar continues for at 
least an hour, owing to a process of fermentation which produces it 
from glycogen. From these and other experiments it is believed 
that the glycogen stored in the liver is constantly but gradually con- 
verted into sugar, which is carried off in the general circulation in 
such small quantities that it is often difficult to detect its presence 
in the blood. 

Glycogen is found in the muscles, and in some other tissues of 
the body, and it has been suggested that sugar might be formed in 
the blood vessels, quite independently of the liver, by a ferment car- 
ried in the blood, but the hepatogenous origin of the glucose is the 
view generally accepted at present. 



THE PANCREAS AND DIABETES 

Extirpation of the pancreas in man has been shown by William 
T. Bull to sometimes produce diabetes, and experimental extirpation 
of this gland in dogs has the same result. In many, but not all fatal 
cases of diabetes, more or less pancreatic disease, usually of the 
nature of chronic interstitial inflammation, has been observed. The 
gland is known to produce an internal secretion — i. e., a secretion 
passed into the circulation, which is a glycolytic ferment — and when 
the gland is diseased this ferment is reduced in quantity, sugar fails 
of conversion to glycogen, and diabetes results. Opie believes that 
the islands of Langerhans are the structural portions of the pancraes 
concerned with the production of the ferment, and degenerative 



DISEASES ESPECIALLY INFLUENCED BY DIET 66l 

changes have been observed in diabetes in these islands of polygonal 
cells which are supplied with a rich capillary network. 

THE NERVOUS SYSTEM AND DIABETES 

It is a curious fact that the irritation or puncture of a very cir- 
cumscribed area in the floor of the fourth ventricle in the medulla is 
followed by the appearance of sugar in the urine. This spot is 
called the " diabetic centre," and it is in close relation with the sym- 
pathetic and vasomotor nerves that control the capacity of the he- 
patic blood vessels. In animals in which fatty degeneration of the 
liver cells has been artificially produced by metallic poisoning, punc- 
ture of the diabetic centre produces glycosuria. Glycosuria is also 
observed in men after the inhalation of chloroform and in animals 
after the inhalation of irritant vapours and after stimulation of the 
pneumogastric nerve. Schiff produced glycosuria experimentally by 
the removal of the spleen from animals, but it does not follow this 
operation in man. He also tied off successive portions of the liver 
from connection with the circulation, and found the production of 
sugar proportionately decreased. The frog is capable of surviving 
extirpation of the liver for three weeks, and at the end of this time 
no sugar is found in the blood (Schiff). If the vagus nerve is di- 
vided in the neck, or if the spinal cord be divided above the origin 
of the great sympathetic nerve, diabetes may result. Bernard sug- 
gested that glycosuria might be cured if it were possible to galva- 
nise the sympathetic nerves. The foregoing experiments demon- 
strate that glycosuria may be caused by a variety of nerve lesions 
and irritations. It is also frequently associated with modifications 
in the activity of the hepatic circulation. 

THE CIRCULATION AND DIABETES 

The occurrence of diabetes in connection with acute inflamma- 
tions of the liver and passive hepatic congestion secondary to ad- 
vanced cardiac disease favours the hypothesis that glycosuria may be 
developed by an increase in the amount of blood flowing through 
the liver, which is thereby stimulated to an active conversion of its 
glycogen into sugar, or else the blood passes so rapidly through the 
liver that the sugar absorbed from the food by the branches of the 
portal vein does not have time to be converted into glycogen, but 
goes through the liver into the general circulation unaltered. Thus, 
whether the glycogenic function be increased or diminished in gly- 
cosuria, either condition would demand altered activity of the portal 
circulation. 

VARIOUS THEORIES OF DIABETES 

Huppert, Pettenkofer, and Voit advocate the following theory: 
Sugar, like urea, is a normal product of the decomposition of albu- 



662 DIET IN DISEASE 

minous bodies. In health the sugar is oxidised; in diabetes less 
oxygen than normal is absorbed, owing to the destruction of the 
red blood-corpuscles occasioned by malnutrition ; therefore sugar 
accumulates in the blood. Sugar is formed from the albuminous 
constituents of the body which undergo rapid chemical change. 
This fact they regard as proved by the increase in the quantity of 
urea eliminated. Von Mehring found sugar in the urine of a dia- 
betic patient after a twenty-six hours' fast. 

Porter believes that the renal epithelial cells, which he claims are 
frequently enlarged in diabetic patients, take an active part in the 
manufacture of glucose because the blood of diabetic patients never 
contains enough sugar at any one time to account for all which is 
found in the urine. The epithelial cells are supposed to manufac- 
ture the sugar out of carbon dioxide and water. This theory lacks 
confirmation, however, and it should be observed that a very small 
amount of sugar, which furnishes a mere trace in the blood at any 
one time, but which is constantly eliminated from the large quantity 
of blood continually passing through the kidneys, may amount in 
the course of twenty-four hours to a number of grammes. In view 
of the established facts in regard to the glycogenic function of the 
liver, it seems unnecessary to believe that the renal epithelium exer- 
cises any special metabolic power in diabetes ; moreover, the kid- 
neys may appear quite normal in severe cases of diabetes. 

Brunton reports several cases due to the presence of a tape- 
worm. He thinks that the increased appetite caused by the presence 
of the worm may have been instrumental in causing the glycosuria 
from overeating, but it is possible that the peripheral irritation of 
sympathetic nerve fibres may have been conveyed to the diabetic 
centre in the medulla, and thence reflected to the vasomotor system 
of the liver. 

Some recent experiments and clinical observations justify the 
belief that the skeletal muscles play a more important role in the 
production of diabetes than has heretofore been supposed. 

During their activity they normally consume glycogen in con- 
siderable quantity. If they fail to perform this function properly, it 
accumulates in the system. 

Kiilz has shown that muscular activity favours the consumption 
of sugar in the organism of the diabetic, and that much less sugar is 
eliminated while such patients are taking vigorous exercise. 

It must be admitted that there are many hepatic diseases and 
lesions in which a large part of the secreting surface of the organ is 
destroyed, and in which glycosuria may never be present, but in 
these conditions it is possible that while a part of the liver is totally 
destroyed there may be some remaining cells which are still endowed 
w r ith normal functional activity, whereas in the disease under discus- 
sion it is probable that none of the parenchyma of the liver main- 



DISEASES ESPECIALLY INFLUENCED BY DIET 663 

tains its normal control over metabolic processes, and hence, what- 
ever sugar is brought to the organ by the portal vein passes into the 
general circulation unaltered. In the graver forms of diabetes, in 
addition to the functional disturbances of the liver, there is believed 
to be present also a condition of malnutrition in which sugar either 
fails to. be consumed or, as suggested by Yeo, " we may suppose that 
in these cases a morbid ferment is formed in the system, possibly in 
connection with some radical fault of stomach or intestinal digestion, 
and that this determines the rapid reconversion of glycogen into 
sugar." 

Symptoms. — The most important symptoms of a typical case of 
diabetes which are to be combated by diet are (a) extreme thirst, 
(b) the large quantity of urine voided and rapid emaciation and loss 
of strength. 

(a) Thirst. The Month. — Thirst becomes excessive, and is not 
quenched by drinking, although patients will drink almost any avail- 
able fluid — even their own urine — in their endeavour to relieve it. 

The absorption by the blood vessels of fluid from the tissues is 
held to be the main cause of this thirst (Vogel), which is most in- 
tense one or two hours after meals, when sugar formation is most 
active, and ten or fifteen quarts of water may be consumed daily if 
patients are not restrained from drinking freely. 

The saliva is thick, frothy, and acid, and often contains sugar. 

The mouth becomes sticky or dry, even to the extent of interfer- 
ing with articulation, and there is often a sweetish taste, which may 
be accounted for by the sugar present in the saliva and the blood of 
the capillaries which circulate among the taste bulbs. 

The tongue is at first moist and sticky and coated with promi- 
nent papillae ; later it may become dry, dark red, and fissured. The 
appetite is at first excessive ; it amounts to bulimia in some cases ; at 
other times it is capricious or intermittent, and subsequently it fails 
completely when the digestion becomes impaired through the symp- 
toms of gastric and intestinal catarrh. 

(b) The Urine. — The average quantity of urine voided is between 
two to three times the normal amount — that is, from 3,000 to 4,500 
cubic centimetres. If water is being drained from the tissues the 
quantity of urine voided may exceed the amount of fluid ingested, 
but obviously this condition cannot last very long. Exceptionally 
as much as 5,000 to 6,000 cubic centimetres or more may be voided 
within twenty-four hours. 

Frequent calls to micturate at night greatly interfere with the 
patient's rest. As a rule, the more sugar present the paler is the 
urine, and it grows turbid soon after standing, from the development 
of yeast fungus (Tonda ccrcvisid), derived from the atmosphere. 
The sediment, if present, is usually light, and the odour may resemble 
whey or hay. The urine is sweetish ; the reaction is usually acid, 
44 



664 DIET IN DISEASE 

but may be neutral or alkaline, and the acidity is usually pro- 
portionate to the quantity of sugar ; it is increased by development 
of carbon dioxide and acetic acid, products of fermentation. After 
standing it does not become alkaline from ammoniacal fermen- 
tation, but undergoes saccharine fermentation. In a majority of 
cases the specific gravity is considerably higher than the normal, 
rising to between 1.035 and 1.050 or more. Bouchardat reports a 
case with a specific gravity of 1.074, and Pavy one with a specific 
gravity as low as 1.010, which is certainly exceptional. It should 
be remembered that the quantity of urea present as well as sugar 
affects the specific gravity. 

The urea is proportionate to the amount of proteid food elements 
ingested, and as patients are usually fed upon nitrogenous food, urea 
is naturally increased beyond the normal average. Sometimes two or 
three times the normal quantity is excreted. Urea, however, always 
exists in small proportion in comparison with the whole quantity of 
urine voided. There are some instances in which there is appar- 
ently an increased waste of the albuminous tissues of the body, re- 
sulting in the production of more urea. 

The quantity of sugar present varies greatly ; an average may 
be stated as from thirty-two to thirty-five parts per thousand 
of urine, but the total may even exceed five hundred grammes 
per diem. 

The effect of a heavy meal of starchy food in increasing the 
sugar is promptly shown by the urine, usually within two hours, and 
it lasts during several hours. In some cases very little sugar is 
eliminated, and yet the symptoms are very severe ; in others a great 
deal is voided and the symptoms are not at all severe, but as a 
rule applying to a majority of cases, the severity increases or dimin- 
ishes with the quantity of sugar passed. After grape sugar has dis- 
appeared during dietetic treatment, inosite is sometimes found in 
the urine, as in simple polyuria. Other substances found occasionally 
in connection with sugar are acetone, alcohol, alkapton, diacetic acid, 
aceton, /3-oxybutyric acid, peptones, and fat (lipuria). More or 
less albuminuria is observed. 

While dietetic treatment is in progress the urine should be peri- 
odically tested with careful relation to the ingested food, and speci- 
mens should be examined which are passed from two to four hours 
after eating various articles of diet in order to observe as exactly 
as possible the influence of such diet upon the elimination of glu- 
cose. 

The Skin and Bowels. — Because so much water is eliminated in 
the urine there is scarcely any perspiration, and the skin becomes 
dry and wrinkled, the face looks drawn and pinched, and the eyes 
are hollow T . In advanced cases a sweetish, sickening odour is ex- 
haled from the skin and in the expired air. From lack of intestinal 



DISEASES ESPECIALLY INFLUENCED BY DIET 665 

secretion the bowels are usually constipated, although diarrhcea may 
alternate with constipation in the later stages of the disease. 

Hunger. — At first the food eaten does not supply the needs of 
the body and there is constant craving for more. 

To -obtain the requisite carbon from fats a labourer, taking his 
ordinary allowance of proteids, would in addition have to eat about 
three hundred and fifty grammes of fats, which would be manifestly 
impossible. The diabetic is practically in this position when all 
carbohydrates are denied him, and a much larger bulk of food is 
necessary for him than if he could eat food containing more carbon 
but less protein. This accounts in a measure for the extreme hunger 
which is felt by many diabetics when suddenly deprived of their ac- 
customed starchy foods. 

Later Symptoms. — In the later stages of the disease dyspeptic 
symptoms are prominent with flatus, sour eructations, and a disgust 
for all kinds of food. The teeth decay, the gums become tender, 
and mastication is difficult. 

The alimentary canal is frequently the seat of chronic gastric 
catarrh, with thickening of the mucous lining of the stomach and 
small intestine. Diarrhcea may be caused by the excretion of sugar 
from the intestinal mucous surface. Occasionally nausea and vom- 
iting are present, and the ejecta may contain acetone. The secre- 
tion of bile is lessened. Emaciation sooner or later becomes extreme 
and progresses, although the appetite remains normal or may be still 
increased. 

The loss of weight, which is so pronounced a feature of most 
advanced cases of diabetes, is attributed in part to the non-burning 
of carbohydrates, and in part to the loss of their albumin-protecting 
action (Graham Lusk). In health, oxygen is used to consume sugars, 
which in diabetes, when sugars are withheld, burns the fat of the 
body instead, so that the quantity of oxygen inhaled and carbon 
dioxide exhaled may remain nearly identical in the two conditions, 
while emaciation progresses. In addition to lack of nitrogen of 
the tissues the wasting is also in part to be accounted for by the 
drain of fluid from the system which takes place when once over- 
action of the kidneys is established. Phthisis is often present and 
increases the rapidity of the emaciation. Exceptionally, early in 
the disease the patient, owing to the greater appetite and the large 
amount of fluid drunk, may increase somewhat in weight. Muscular 
weakness and debility rapidly supervene to a greater extent than is 
to be accounted for by the usual loss of flesh. 

In general, it may be said in the milder forms of diabetes that the 
sugar in the urine is derived from carbohydrate foods, while in the 
more serious forms it is also derived from the nitrogenous metab- 
olism. The sugar which is eaten as food or which is formed by 
starch in the alimentary canal, after absorption is mainly used under 



666 DIET IN DISEASE 

normal conditions in the production of force, but in diabetes it is 
eliminated unaltered from the body, and there is consequent lack of 
heat production and muscular power. 

Since a large amount of heat-producing material passes from the 
body without complete oxidation, the body temperature is not in- 
frequently subnormal; and it may so remain throughout the disease 
unless there be some inflammatory complication. The axillary tem- 
perature m#y be gy° or even 95 F. The occurrence of any acute 
joint or visceral inflammation or of any acute fever causes a reduc- 
tion in the quantity of sugar eliminated while the pyrexia lasts. The 
explanation of this fact is by some observers thought to be due to 
increased combustion of sugar in the body during the pyrexial stage, 
but Bernard attributed it to an interference with the glycogenic 
function of the liver. The pulse becomes rapid and feeble and the 
temperature is subnormal. 

When great feebleness compels the patient to become bedridden, 
bedsores and excoriations from frequent passage of acid and sac- 
charine urine add to his discomfort. 

Diabetic coma is the precursor of sudden death in a certain num- 
ber of cases, and it is also to be regarded as the worst possible symp- 
tom which may arise. Many theories have been offered in explana- 
tion of this symptom, and the one which is at present in vogue is 
that it is produced by an acid intoxication produced by accumulation 
in the system of /3-oxybutyric acid, constituting an acidosis (Nau- 
nyn). This acid is found in the tissues and blood, and also, in com- 
bination with bases, in the urine. The acid is derived from tissue 
albumins, and possibly fats, and over 200 grammes may be present 
in the tissues in a fatal case. Gangrene, asthenia, or intercurrent 
diseases cause a number of deaths. 

There are other symptoms affecting the nervous system, the eyes, 
etc., and there are many complications which may arise in the course 
of the disease, but a consideration of them would lead too far from 
the object of the present discussion, which is to deal with those 
symptoms which bear a more immediate relation to the metabolism 
of the food. 

Some of the complicating diseases with which diabetes may be 
associated make it impossible to adhere to a rigid regimen without 
producing more harm than good. Such, for example, are acute gout 
and chronic nephritis, in both of which a meat diet is injurious, and 
if carbohydrates are also cut off the patient has little or nothing 
left to eat. In these cases the diet must be determined by whichever 
constitutes the graver complication (see p. 496). 

Course. — The course of diabetes is so protracted that there is 
abundant opportunity and usually necessity for trying dietetic ex- 
periments, for it will be found impossible to establish rules for die- 
tetic treatment to which exceptions may not arise from time to time 



DISEASES ESPECIALLY INFLUENCED BY DIET 667 

in the course of any individual case. The disease is sometimes well 
established long before its symptoms become sufficiently urgent to 
attract .the attention of the patient. Persons who believe themselves 
to be in perfect health and who apply for life-insurance examination 
may be informed for the first time of the presence of glycosuria, 
and many cases are now discovered through incidental examination 
of the urine in connection with some other disease, which would have 
been overlooked a few decades ago, when clinical urinalysis was very 
imperfect. 

If treatment is begun before the symptoms are well advanced 
the lives of many patients may be prolonged — in some cases for more 
than ten or twelve years — whereas, of seven hundred cases reported 
by Prout which occurred over thirty years ago, only two patients 
lived beyond ten years. Frerichs reported one case which extended 
through twenty years and several more in which the disease lasted 
between ten and eighteen years. Occasionally diabetes is extremely 
acute, and may prove fatal within three weeks, but in such instances 
it is probable that glycosuria has been present for a long time with- 
out discovery. 

Prognosis. — Between 50 and 60 per cent of all cases are fatal in 
less than three years ; undoubtedly a few which are recognised 
sufficiently early may be completely cured, but glycosuria, like al- 
buminuria, indicates a weakness of the system in a special direc- 
tion, and, the disease having once occurred, the patient should be 
under reasonable supervision for many years. It has been aptly 
said that " the only chance that a diabetic has of being cured is to 
believe that he never is cured " — that is, to be constantly on the alert 
to avoid all indiscretions in hygienic and dietary matters. There 
seems to be a relation between the general bodily nutrition and the 
chance of recovery or improvement. Usually stout, middle-aged 
men yield best to treatment ; thin persons withstand the disease less 
well, and rapid emaciation is always more to be dreaded than the 
presence of sugar. The prognosis is more favourable in those cases 
which are readily amenable to the influence of a strict dietetic regi- 
men. The prognosis is more favourable if the sugar does not 
speedily return if the dietetic treatment be interrupted, and also 
if the amount of urea excreted is large and the quantity of uric acid 
small. Cases which occur in connection with gout are relatively 
light. In emaciated cases the malnutrition is so great that the pa- 
tients easily acquire other diseases, especially pulmonary tubercu- 
losis, and many die from complications rather than from the imme- 
diate effect of the disease itself. 

Diagnosis. — To determine the presence of permanent glycosuria, 
the patient should be placed for two days upon a standard diet con- 
taining no other carbohydrate food than 100 grammes of wheat bread 
(von Noorden). The urine passed during twenty-four hours is then 



668 DIET IN DISEASE 

collected and analysed by polarisation and titration or fermentation. 
If sugar be present, the carbohydrate allowance should be varied for 
a day or two, in order to determine its effect upon the quantity of 
sugar eliminated, and serve as a guide for dietetic treatment. Tem- 
porary glycosuria may be caused by a variety of conditions, such as 
excessive indulgence in sweets, poisoning from amyl nitrite, mer- 
cury, chloroform, alcohol, etc. It has been observed during preg- 
nancy and after anthrax, diphtheria, scarlatina, typhoid fever, etc. 
In the transient form of glycosuria the urine contains much less 
sugar than in diabetes mellitus, and all the severe symptoms of ex- 
cessive thirst, emaciation, and extensive tissue waste, leading to local 
disease and usually death, are wanting. 

In polyuria or diabetes insipidus there is no sugar in the urine, 
and the specific gravity is very low — 1.002 to 1.005. 

Primary peptonuric diabetes is described by Quinquand as a dis- 
ease presenting the clinical features of mellituria — thirst, marked 
cachexia, polyuria, etc. — but instead of sugar, the urine contains 
peptones ; it polarises to the left, and is of low specific gravity. 

Temporary lactosuria sometimes occurs as an accompaniment of 
the puerperal state, and is not of special dietetic significance. 

Treatment. — The treatment of diabetes to-day is much more 
successful than it was thirty or forty years ago, when every case was 
regarded as necessarily fatal. The treatment should be (1) prophy- 
lactic, (2) dietetic, (3) hygienic, and (4) medicinal. 

Prophylaxis. — Until more is known of the aetiology of diabetes 
definite prophylactic rules cannot be established; but in general, 
where there is distinct heredity to be feared, or when the lithic-acid 
diathesis exists, all excitement of the nervous system, mental or 
physical, as well as indulgence in alcohol and sweets, should be stren- 
uously avoided. 

Dietetic Treatment. — General Observations. — When prescribing 
any dietetic regimen for diabetic patients, the general condition of 
bodily nutrition must be carefully considered. Obese, naturally 
robust, and sometimes gouty patients will be benefited by very 
strictly limited and carefully regulated diet, but emaciated and feeble 
patients cannot always endure the severity of a strict diabetic 
diet without too great loss of vitality, and it becomes necessary to 
maintain their strength even at the cost of sometimes increasing the 
amount of sugar in the urine. Obese persons make their fat largely 
out of carbohydrates, and hence a nitrogenous diet is particularly 
well suited to their condition, whereas emaciated, weak patients gain 
no flesh upon an exclusive nitrogenous diet, and it may barely sup- 
port life for them. 

Some persons with diabetes have been said to excrete more sugar 
on a diet of animal food than on the hydrocarbons, but it will gener- 
ally be found that such patients have eaten some farinaceous food, 



DISEASES ESPECIALLY INFLUENCED BY DIET 669 

bread, etc., with their meat, and the combination seems particularly 
favourable to the maintenance of a secretion of saccharine urine once 
established. Such patients may be temporarily given a diet in which 
fat in great part replaces meat, the fat being eaten with those vege- 
tables which contain a minimum of starch and sugar (see p. 135). 

Regulation of the diet should be faithfully tried before any medi- 
cation is resorted to, for the latter frequently becomes superfluous, 
but a placebo may be given if necessary. During the siege of 
Paris in 1871 it was observed that a number of diabetics im- 
proved considerably owing to the enforced restriction in their diet 
(Bouchardat). 

Cantani advises a preliminary fast of twenty-four hours before 
commencing dietetic treatment, but the value of this expedient is 
questionable. 

Phenomenal improvement follows in many cases upon a diet 
which excludes starches and sugars almost completely, but this is a 
difficult regimen to enforce, for the craving for carbohydrates, espe- 
cially for bread, becomes so fierce that patients whose veracity is 
otherwise unimpeachable will resort to lying or any form of decep- 
tion to obtain this coveted food. 

It is a matter of common experience that the most difficult of 
all food for a man to be deprived of, when once accustomed to it, is 
bread. This has always been found to be the case in arctic expedi- 
tions in which men have been reduced to a starvation dietary, and it 
is usually observed in any form of largely restricted diet, although 
patients who are living upon an exclusive diet of milk appear to 
have somewhat less craving for it than diabetics, who are allowed a 
greater variety of food, especially meat. This is due in part to life- 
long association of certain kinds of food with one another at meals 
and the habit of eating this one article of food with more constancy 
than any other, but it is also undoubtedly referable to a positive 
craving of the system, which is particularly marked in diabetes, for 
a kind of food which the tissues need but cannot assimilate. For 
this reason it is generally advisable to allow patients from two to 
four or even six ounces of bread a day in divided portions ; other- 
wise the craving for it does them positive harm, and a loathing for 
all food results, or they break all restraints and injure themselves 
more by overeating. 

It should be remembered that diabetic patients are very sus- 
ceptible to the influence of the nervous system, and that worry and 
anxiety about themselves, with too close an observation of their 
own diet, will often react unfavourably. Moreover, it is undoubtedly 
much harder for these patients to restrain themselves from eat- 
ing varieties of food which are not wholesome for them if they sit 
at a general table where others are indulging in various luxuries of 
the season. It is sometimes possible for them, as has been proved 



670 DIET IN DISEASE 

by Cantani, to maintain good health for many years upon a strictly 
nitrogenous diet, but in attempting to enforce any rigid dietetic sys- 
tem one is compelled to have some regard for the environment and 
general habits of life of the patient, and it is easy to make the indi- 
vidual so miserable by too harsh rules as to defeat the very object in 
view, and the adoption of a too restricted system of diet may result 
in disastrous failure. For these reasons it is now customary to allow 
patients a more liberal dietary in diabetes than was at first permitted 
after the discovery of the real nature of the disease and the influence 
of carbohydrates upon it, but they should always be given carefully 
written directions as to what articles they may eat and what must 
be avoided. 

While it is necessary to secure the intelligent co-operation of the 
patient in regard to carrying out his treatment, it is highly undesir- 
able that he should devote too much time and attention to it, and, 
when possible, it is better to have some one else select and provide 
food for him in order that his mind may not be constantly occupied 
with questions of dietetics which tend to restrict the appetite, and 
sometimes to materially interfere with the beneficial effects of the 
diet. There is the more need for supervision of the diet by a second 
person, because the craving of diabetic patients often attains an 
ascendency over their will power and habits of truthfulness ; in fact, 
a lack of mental force and even imbecility are quite characteristic of 
the advanced disease. 

Deception should be suspected in those cases in which there is 
more urine passed than is to be accounted for by the quantity of 
fluid allowed in the diet, and in those cases which apparently ought 
to improve upon dietetic treatment, but in which after repeated 
trials no headway is made in regard to controlling the amount of 
sugar in the urine. I have known hospital patients to steal bread 
and potatoes and consume them surreptitiously in spite of repeated 
warnings, and also to acquire such a craving for fluid as induced 
them to drink their own urine. 

With regard to the suddenness with which the diabetic regimen 
should be adopted by the patient, it is found to be the rule that it is 
easier for most patients to begin with the fully restricted diet at 
once than to gradually eliminate one article after another from the 
menu. The urine should always be thoroughly examined, both quali- 
tatively and quantitatively, for sugar, urea, and albumin, before the 
restricted diet is commenced, and periodic examinations must be 
made during the course of the treatment in order to determine the 
effect upon the disease of withholding different articles of food 
and drink. 

At first it is well to make such examinations daily, and subse- 
quently, if the patient is doing well, once or twice a week is suf- 
ficient. 



DISEASES ESPECIALLY INFLUENCED BY DIET 67 1 

The effect of no dietetic system is immediate, and at least two 
days may be required for the patient to come fully under the influence 
of treatment, because the materials already present in the body when 
the new diet is commenced may serve as a source of sugar for some 
little time afterwards. 

The general principles for the dietetic treatment of diabetic pa- 
tients are, first, to exclude from the diet, when possible, all those 
articles which are most likely to result in the formation of sugar; 
secondly, to devise means for relief of the craving for starchy and 
saccharine foods which patients kept on a nitrogenous diet are cer- 
tain to experience before long, and to see that while reducing the 
amount of sugar in the food, the patient is not suffering to a danger- 
ous extent from lack of nutrition. It is difficult to formulate rules 
of diet which can be adhered to in all cases. There are many pa- 
tients confined to an exclusive nitrogenous diet who lose flesh and 
strength so rapidly that although the advantage of reducing the 
glycosuria is attained, a new danger arises from anaemia and 
emaciation. 

For convenience of description of dietetic treatment cases of 
diabetes may be subdivided into three classes : (a) Those patients 
who pass a considerable quantity of urine containing a large percent- 
age of sugar, but in whom the general health is still good, (b) Cases 
in which, in addition to the passage of considerable sugar in the 
urine, there is more or less dyspepsia, emaciation, and debility, (c) 
Cases in which the constitutional symptoms become rapidly severe 
after the first appearance of sugar in the urine. 

(a) In the first class of cases the dietetic treatment is productive 
of the greatest benefit, and not rarely the patients begin to gain 
flesh and strength ; they sleep better ; the daily quantity of urine 
falls perhaps from three hundred ounces to seventy, and it ap- 
proaches the normal composition; the excessive appetite and thirst 
diminish ; the digestion improves, and in one to three weeks the 
sugar may entirely disappear. Such patients are not to be regarded 
as cured, however, as soon as the sugar disappears — not, in fact, until 
they can eat starches in ordinary quantity without exciting the ap- 
pearance of glycosuria. According to the statement of Dujardin- 
Beaumetz, patients of this class may be cured who have been elimi- 
nating as much as three thousand grains of sugar per diem. When- 
ever sugar, or amylaceous food absorbed as sugar, passes through 
the circulation unaltered, it is of no value to the system, and, as 
Bauer says, it serves merely as " useless ballast." 

(b) The second class of cases is also amenable to dietetic treat- 
ment, but the benefit is not so immediate and usually not so great 
as in the first group, and it may be impossible to cause the total dis- 
appearance of the sugar, although it may be reduced to two hundred 
or three hundred grains a day. When the amount of urine is less- 



6/2 DIET IN DISEASE 

ened by the changes of menu, the specific gravity remains high, and 
sugar is abundant, the prognosis is very grave. The patient cannot 
tolerate the diet, and drugs must be resorted to. 

(c) In the third and most severe class of cases dietetic treat- 
ment is sometimes of avail, and it should be always undertaken, for 
it may prevent the patient from becoming worse, although it is un- 
able to accomplish a cure. 

But usually the treatment of these cases is unsatisfactory, be- 
cause the patients, who are often young subjects, continue to form 
sugar from nitrogenous food after starches and sugars have been 
proscribed, and it is practically impossible to devise any special com- 
bination of food, or to find any single food upon which they can sup- 
port life and from which they are not able to produce sugar. Their 
nutrition is extremely poor, and they go rapidly from bad to worse. 
Not seldom they are thin, neurotic subjects when the disease first 
attacks them, and therefore have very little capital to draw upon. 
In extreme cases a careful comparison between the amount of food 
ingested and sugar eliminated has furnished evidence that they are 
even capable of manufacturing sugar or glycogen out of the muscu- 
lar tissues of their own bodies. 

A clinical comparison of the different varieties of diabetes above 
described, with the theories which have been discussed in regard to 
the possible method of the production of the disease, emphasises the 
conclusion that cases of diabetes may not all have exactly the 
same aetiology. 

By different writers all gradations of diet have been recom- 
mended, so long as the carbohydrates are restricted, from the ab- 
solute meat diet of Cantani to the skim-milk diet of Donkin and the 
more liberal menu of the majority of authorities. 

Some patients who have a very good appetite when allowed a 
mixed diet lose it altogether when put upon an exclusive nitroge- 
nous regimen. There are those who can live contentedly on an ex- 
clusive diet of proteid food and fats for a certain length of time — 
say ten days or a fortnight — if the principle of the treatment be ex- 
plained to them and they are anxious of being cured, but sooner or 
later they almost always find it intolerable to wholly abstain from 
starchy and saccharine foods, and many prefer to live less long, 
but in more comfort than such restriction implies. This is prob- 
ably attributable more to long-continued habit or heredity than 
actual inability to support life on a purely nitrogenous diet, for, 
as stated elsewhere (p. 316), the Eskimos thrive upon a diet ab- 
solutely free from starches and sugars of every kind. It is be- 
lieved by Ebstein and others that an exclusive meat diet may be 
injurious on account of a tendency to produce acetonemia, and it 
may favour the increase of uric-acid deposits in those having the 
uric-acid diathesis. To obtain enough carbon from such a diet for 



DISEASES ESPECIALLY INFLUENCED BY DIET 673 

the needs of the system, a very large quantity of proteid food must 
be consumed. 

When chronic nephritis complicates diabetes the difficulty of 
dieting is much enhanced, for meat is injurious for the nephritis, 
and starches are prohibited in diabetes. This condition has 
been aptly described as the " Scylla and Charybdis of the dia- 
betic." As a compromise such patients must usually be put upon 
a milk diet. 

Dujardin-Beaumetz states that when the quantity of sugar elimi- 
nated falls to ten grammes a day, less rigorous withholding of 
starches is needed. 

Mild cases of diabetes seldom occur in children, hence the diet 
for them must be even more closely confined to proteids than for 
adults. 

Many elaborate diet tables have been prepared, and for those 
whose means permit of indulgence in delicacies considerable variety 
may be secured without the use of carbohydrates ; but for the poor 
in hospitals and at home it is a difficult problem to furnish inexpen- 
sive variety without occasional recourse to starchy foods. 

Foods allowed in Diabetes 

Soups and broths made of meat of any kind without vegetables, 
ox-tail and turtle soup, gumbo, curry. 

Eggs in any form. 

Crustaceans, crabs, lobsters, shrimp. 

Fresh fish of all kinds and fish roe. Caviare, anchovies. Salt 
fish, cod, mackerel, and herring may be allowed, unless they increase 
thirst too much. 

Fresh meat, fowl and game of all kinds. Ham, bacon, smoked 
beef, tongue, sweetbreads, kidneys. 

Fats. — Olive oil and all animal fats and oils, such as butter, 
cream, cod-liver oil, bone marrow. Some authorities, however, 
exclude all fats. Senator objects to them on the ground that they 
form glycerin. Cantani excludes butter because it may contain some 
milk sugar. But usually such rigidity is unnecessary. In some dia- 
betic patients the power of fat digestiota is apparently increased, so 
that they tolerate larger quantities than in health. 

Vegetables. — Spinach, cress, sorrel, chicory, romaine, dandelions, 
beet tops, horseradish, radishes, celery, sea-kale, artichokes, vege- 
table marrow, okra, lettuce, endives, pickles, cucumbers, gherkins, 
cranberries. The following vegetables are allowed by some writers, 
prohibited by others : green French string beans, asparagus, summer 
squash, onions, leeks, carrots, cauliflower, cabbage, sauerkraut, cole- 
slaw, kohl-rabi, parsley, parsnips, eggplant, artichokes. 

Because potatoes contain somewhat less starch than is found in 



674 DIET IN DISEASE 

bread they may sometimes be allowed in moderation when the latter 
is found to disagree. Germain See gives five ounces of potato meal 
daily as a substitute for bread. 

The following statement made by Fagge is useful : " The general 
rule is that all white parts of vegetables in which chlorophyll has not 
been developed by exposure to sunlight contain no sugar, and are 
not harmful. But by boiling in a large quantity of water, even the 
forbidden kinds of vegetables, if they contain sugar only and not 
starch, may be rendered much less injurious." There is a decided 
advantage in using such green vegetables as are allowed in diabetic 
diet on account of their adding to the bulk of waste matter in the 
intestine and preventing constipation, which almost inevitably re- 
sults from a meat diet. 

Miscellaneous. — Kidneys, tripe, pig's feet, truffles, mushrooms, 
sweetbreads, terrapin. 

Cheese, cream cheese, milk curds. 

Jellies made of gelatin, calf's foot, with wine, but unsweetened 
except with saccharin, coffee jelly, lemon jelly. 

Fruits, if acid, not sweet. In England, where gooseberries are 
eaten much more than in this country, they, as well as apples, red 
currants, and sour cherries, are sometimes allowed. Many of these 
fruits contain more levulose than grape sugar. Sour oranges, 
lemons, grape fruit, olives, sour apples, peaches in brandy (without 
sugar), raspberries, and strawberries are allowed by some, but are 
usually forbidden. Muskmelons and watermelons may sometimes 
be eaten. 

Nuts. — Oily nuts, such as almonds, walnuts, Brazil nuts, hazel- 
nuts, filberts, pecan nuts, butternuts, cocoanuts. 

The articles above enumerated afford considerable choice, and it 
is to be distinctly understood that only so many of them are to be 
allowed at a time as may serve to divert the craving of the patient 
from his chief enemy — concentrated hydrocarbons. Some patients 
will be found who can eat any of the above articles with impunity, 
while others can take but very few, and others can consume certain 
foods for a short time without increasing their sugar elimination, 
which suddenly will be found to agree no longer, when some other 
food must be at once substituted. 

It is apparently true that there are some individuals for whom 
one or two articles of starchy food can be found which do not pro- 
duce sugar in the urine. Fothergill reports several cases of this kind. 
One of his patients passed urine free from sugar while eating vermi- 
celli pudding and arrowroot. Another one took raspberry jam with 
impunity. When such cases are thoroughly investigated, however, 
it is usually found that they have reached an intermittent period in 
the activity of the disease which is not infrequent in this chronic 
affection, and in which for the time being the patient is very much 



DISEASES ESPECIALLY INFLUENCED BY DIET 675 

better, and the urine remains for a little while practically normal. 
Such instances occur in the milder types of cases. 
The following articles are absolutely 

Forbidden Foods 

Sugar in any form — sirup, molasses, confectionery, jams, and 
sweets of all kinds. Honey is forbidden, for it contains both dex- 
trose and levulose. 

Starches. — All the elementary forms of starchy and farinaceous 
food, such as rice, sago, tapioca, arrowroot, oatmeal, cornmeal, 
hominy, samp, buckwheat, barley, semolina, macaroni, spaghetti, 
vermicelli. All pastry, cake, puddings, pies of every description — 
in short, everything made of flour excepting a little bread as speci- 
fied above. 

Vegetables. — Potatoes, beets, carrots, parsnips, turnips, peas, 
beans (except string beans), lentils, cauliflower, broccoli, Brussels 
sprouts, rhubarb. Some writers, like Dujardin-Beaumetz, occasion- 
ally allow a well-baked potato in mild cases. It contains only 15^ 
per cent of starch, or one fifth as much as rice, and one half as much 
as peas and beans. 

Shellfish. — The soft parts or livers of clams, oysters, and mussels 
contain glycogen. By some these foods are entirely forbidden, 
but many diabetic patients can take them occasionally without 
injury. 

Liver of all animals (it contains glycogen), pate-de-foie-gras. 

Fruits. — In regard to the use of fruits there is some difference of 
opinion. Sweet fruits, such as figs, dates, plums, prunes, bananas, 
apricots, all preserved, candied, or sugared fruits must be absolutely 
interdicted. Pears, melons, and berries are forbidden by many, but 
allowed by others. 

Nuts. — Chestnuts, peanuts. 

Substitutes for Bread 

After all, the problem for selecting a suitable starchy food for 
the diabetic is governed as much by the necessity of furnishing 
some form of food which will satisfy the craving for farinaceous 
material as for the actual nourishment which it may contain. 

The most difficult of all starchy food for the patient to forego 
is bread. Much ingenuity has been expended in attempts to devise 
substitutes for it, and many preparations for making artificial breads, 
biscuits, rusk, or cakes with eggs and butter are sold in market for 
this purpose. Some of these are palatable for a time, but many 
have been found to contain 60 or 80 per cent of starch — fully 
as much as wheaten bread — while others contain no nutriment 
at all. 



6j6 DIET IN DISEASE 

Some authorities, as Germain See and Dujardin-Beaumetz, 
advise giving potato meal instead of bread, five ounces per diem, 
which may be cooked in any form without sugar. 

Torrified starch may be used by some diabetics. The starch is 
prepared by baking a large ball of flour so thoroughly that the 
starch granules in the interior of the mass are burst open by the 
heat. Torrified bread or toast consists of thin cut pieces of bread 
which are toasted through and through until almost black before a 
hot fire until both the gluten and the starch are disorganised to some 
extent. Well-browned bread crust is of the same nature. 

The breads made from flour especially prepared for diabetics 
are : (a) Gluten bread; (b) bran bread; (c) almond bread; (d) inulin 
bread ; (e) soya bread. 

(a) Gluten Bread. — Gluten bread was first used by Bouchardat. 
It is made by washing wheat flour in such a manner as to remove 
the starchy granules, leaving the gluten behind. Such bread is cer- 
tain to contain more or less starch, and not seldom it has both 
starch and sugar. It is much more tiresome to eat than any ordi- 
nary bread, and unless prepared by a very reliable manufacturer it 
has little to recommend it. It is not pleasant to masticate, for it is 
often unpleasantly tough and stringy. It is difficult to panify, but it 
may be aerated. Gluten biscuits are more palatable than gluten 
bread, but most of these preparations have the disadvantage of not 
keeping fresh for more than a week or ten days. 

Gluten Hour is used for thickening broths, egg puddings, etc. 

The following are receipts for utilising gluten flour : 

Jeffries s Gluten Biscuit for Diabetics 

Gluten flour i cup. 

Best bran, previously scalded I cup. 

Baking powder (or the equivalent of bicarbonate of soda 

and cream of tartar) I teaspoonful. 

Salt to taste. 

Eggs 2. 

Milk or water I cup. 

Mix thoroughly. 

James Stewart's Diabetic Bread. — " Take one quart of sweet milk 
or milk and water, one heaping teaspoonful of good butter, one fifth 
of a cake of compressed yeast beaten up with a little water, and two 
eggs well beaten. Stir in gluten flour until a soft dough is formed, 
knead as in making ordinary bread, put in pans to raise, and when 
light bake in a hot oven." 

Liebig proposed to prepare bread for diabetics by pouring a 
malt infusion over thinly sliced wheaten bread. The sugar which 
is thus formed is washed away, and the gluten residue may be 
eaten. « -■ 



DISEASES ESPECIALLY INFLUENCED BY DIET 6jy 

It is very difficult to obtain a reliable gluten flour. Much that 
is sold in open market contains more starch than wheaten bread — it 
may hold 60 or 70 per cent (Harrington). 

The gluten flour obtained in the market in London or Paris con- 
tains about 15 per cent of starch, whereas that sold in the United 
States frequently has two or three times as much. 

Tyson, who has investigated the matter thoroughly, states that 
the gluten breads made by Theodore Metcalf, of Boston, and the 
Sanitarium Food Company of Battle Creek, Michigan, contain less 
starch than other American preparations. Pavy recommends a glu- 
ten bread and biscuit made by Bouthrou. A wholly starch-free flour 
does not exist. 

James Stewart gives the following test for starch to be applied 
to gluten flour: A little of the flour is shaken well with boiling 
water, and cooled. A few drops are then added of an aqueous solu- 
tion of iodine and potassium iodide (Gram's solution). If starch 
be present, a decided blue colour develops. 

Dujardin-Beaumetz declares that gluten bread contains more 
than three times as much sugar-forming material as potatoes, and 
hence he prescribes the latter instead. 

Van Abbott recommends the use of gluten macaroni, gluten ver- 
micelli, and gluten semolina, which can be made into puddings with- 
out sugar. 

Fromentine is another form of diabetic flour made from wheat 
germs. They contain less starch than mature wheat, but hold an 
oil which is purgative and which prevents proper panification, and 
causes the bread to sour easily. 

Poluboskos is another form of flour said to contain a minimum 
of starch. 

Embryonine or legumine is a substance isolated from the casein 
of legumes, and which is sometimes given for diabetes. 

(b) Bran Bread. — The use of bran bread was first suggested by 
Prout, but, like gluten bread, it is apt to contain a good deal of 
starch, and in addition tough cellulose, which is of little nutrient 
value and which may prove irritating to the mucous membrane and 
alimentary canal, causing diarrhoea. It is, moreover, somewhat 
tasteless, and patients quickly tire of it. Bran bread cakes may be 
purchased prepared expressly for the use of diabetics. They are 
made according to Dr. Camplin's receipt, as follows : 

Camplin's Bran Bread. — " Boil one quart of wheat bran in two 
successive waters, wash in a sieve with hot water until the water 
runs through clear. Squeeze in a cloth after each washing. Spread 
thinly on a dish, and dry in a slow oven. Grind in a fine mill, and 
sift by brushing through a very fine sieve. Grind the residue again 
and sift. Take of the powder three ounces, three new laid eggs, 
butter two ounces, and half a pint of milk. Mix the eggs with a 



678 DIET IN DISEASE 

little of the milk, warm the butter with the rest. Stir the whole and 
flavour with nutmeg or ginger. Bake in thin cakes in a quick oven 
for half an hour." More eggs may be used, and Roberts adds 
sodium bicarbonate. The object of drying the bran before it is 
ground is to make it friable, otherwise it is too soft to be easily 
powdered. These cakes or biscuits may be eaten with butter or 
cheese, and taken with meals two or three times a day. 

(c) Almond Cakes. — Pavy first suggested the use of almond cakes 
for diabetics, which he prepared by making a meal of sweet almonds. 
This meal when washed in acidulated water is freed from sugar, and 
may be made into cakes or crackers. Seegen gives the following 
receipt for almond cakes : 

Seegcn's Almond-Hour Cakes. — " Take of blanched sweet almonds 
a quarter of a pound, reduce to powder in a stone mortar, steep in 
linen in boiling water, acidulated with vinegar, for fifteen minutes 
to remove sugar. Mix the paste with three ounces of butter and 
two eggs, add the yolks of three eggs, a pinch of salt, stir well. 
Whip the whites of three eggs and stir in. Put the dough into 
greased moulds, dry at a slow fire." Almond-flour preparations 
contain so much fat that they often prove indigestible after a few 
days' trial, and they are relatively expensive. 

Many physicians prefer to discard the use of all substitutes for 
bread, such as bran and almond cakes, and to allow the patients a 
limited amount of plain bread. 

A nut flour, the Chicago Sanitary Flour, is recommended by 
N. S. Davis, Jr., of Chicago. Analysis by Prof. J. H. Long shows it 
to contain : 

Water 8.01 

Fat 19.82 

Albuminoids 55-65 

Sugar 6.25 

Mineral salts 6.32 

Fibre and other non-nitrogenous matter 3-95 

100.00 

It is thus seen to contain no starch, and most of the 6.25 per 
cent of sugar is lost by conversion to C0 2 in the fermentation pro- 
cess of breadmaking. It is useful not only for diabetics but for 
those having flatulent dyspepsia. 

(d) Inulin Bread. — A form of bread has been made by Kiilz 
from inulin and lichinin. Inulin is derived from the root of elacam- 
pane {Inula helcnium). 

Kiilz's Inulin Biscuits. — " Fifty grammes of inulin are to be put 
in a large porcelain basin, and while standing over a water bath to 
be rubbed up with thirty cubic centimetres of milk, and as much 
hot water as may be necessary, into a uniform dough, with which 



DISEASES ESPECIALLY INFLUENCED BY DIET 679 

the yolks of four eggs and a little salt are to be mixed. To this 
the whites of four eggs are to be added, having first beaten them 
to a foam and carefully worked them in. The dough is finally to be 
baked in tin moulds, previously smeared with butter. The taste of 
the biscuits may be improved by the addition of vanilla or other 
spices " (Dietary of the Sick. Von Ziemssen's Handbook of General 
Therapeutics). These biscuits are not agreeable to the taste and 
patients soon tire of them. 

(e) Soya Bread. — A meal is made from the fruit of the Soya 
hispida, a bean which is grown in China and Japan and also raised 
in Austria. It is very rich in protein. It has a peculiar taste and 
holds a purgative oil. 

The published percentage composition of the more important in- 
gredients of soya bread is as follows : 

Water 45 . 000 

Protein 20.168 

Fats 9-350 

Starch and sugar 2 . 794 

Phosphoric acid 0.863 

Soya bread is nutritious on account of the large percentage of 
fat which it contains, but according to an analysis made by an expert 
chemist it contains carbohydrates in considerable amount. This, 
in fact, is true of all the breads and biscuits made of substitutes for 
flour. Prof. Leeds says that some breads which are falsely called 
gluten breads contain from 50 to 75 per cent of carbohydrates, and 
hence they are unreliable and deceptive. 

Substitutes for Sugar 

Kulz states that certain of the sugars and allied bodies may be 
used with the food without increasing the glycosuria, being very 
thoroughly consumed within the body. Such, for instance, are inu- 
lin, inosite, mannite, and levulose or sugar derived from fruits. A 
preparation of the latter is sold under the name of " diabetin." An- 
other sugar substitute known as " crystalose " is much prescribed at 
Carlsbad. 

Glycerin has also been used, but Senator and Frerichs are op- 
posed to it. If given in quantity, such as one or two ounces a day, 
it occasions intestinal disorder, and may prove too laxative. It also 
causes a continuous sweet taste in the mouth. 

Saccharin is employed with success to take the place of cane 
sugar for sweetening foods for diabetic patients. It may be used 
to sweeten coffee and other materials. It is a crystalline nitro- 
genous body derived from coal tar, which is sparingly soluble in 
cold water, more soluble in hot water, and very soluble in glycerin. 
It is about three hundred times as sweet as cane sugar, and when 

45 



680 DIET IN DISEASE 

taken not to exceed four or five grains daily it is quite harmless.. 
Eaten in large quantity it disorders digestion and causes gastric 
pain. A convenient formula is given by James Stewart for sac- 
charin pastilles : 

Saccharin gr. xlv. 

Sod. bicarb, sice 3 ss. 

Manniti 3 xijss. 

M. Make ioo pastilles ; one will sweeten a cup of tea or coffee. 

Cooking. — Care should be exercised in the preparation and cook- 
ing of the food for diabetic patients that injurious ingredients are 
not added for the purpose of flavouring or thickening. For this 
reason all the articles of diet should be cooked as simply as possi- 
ble, and rich sauces containing flour should be forbidden. Melted 
butter may be used as a substitute. Roast beef should not be 
basted with flour, and meat soups must not be thickened. Vege- 
tables which have been boiled for a long time in a large bulk of 
water have most of their sugar dissolved out, and on that account 
are less injurious. 

Very acid fruits may be sweetened with saccharin or cooked 
with a little sodium or potassium bicarbonate to neutralise their 
acidity. 

Beverages 

Water. — It is an important matter to decide to what extent to 
restrict the quantity of water and other fluids drunk by diabetics. 
When so much urine is voided that the patient's rest at night is dis- 
turbed by acts of frequent micturition, it is always annoying, and 
may be even serious. The increased work thrown upon the kidneys 
is less harmful than might be at first supposed, for the water of the 
urine is excreted chiefly by a simple process analogous to filtration, 
which no doubt taxes the renal epithelium less than the excretion of 
some of the solids of the urine. At all events, protracted cases of 
diabetes do not necessarily exhibit serious renal degeneration. 

For these reasons, if the water drunk is restricted, it should be so 
more on account of relieving the patient of an uncomfortable con- 
dition than from fear that the act of passing so much urine may be 
injurious per sc, and the restriction should never be enforced too 
suddenly. As a rule, when dietetic regulation reduces the glycosuria 
and improves the patient's condition there is, pari passu, a reduction 
in the quantity of urine voided. In other words, this symptom takes 
care of itself. A reasonable restriction of the fluids allowed is to be 
recommended, but when thirst is extreme it becomes unendurable 
torture to withhold them rigidly, and, moreover, the water is ap- 
parently needed to wash out the sugar which would otherwise accu- 
mulate in the blood and tissues. In fact, the occurrence of impend- 



DISEASES ESPECIALLY INFLUENCED BY DIET 68 1 

ing coma has been postponed by flushing the circulation by means 
of large draughts of water or enemata of salt water. 

When the thirst leads to excessive drinking, salt foods and condi- 
ments should be withheld, and some relief may be obtained by suck- 
ing a slice of lemon or by using a little potassium bitartrate and 
lemon juice, or dilute phosphoric acid in water. The patient should 
drink only from a small glass, for there is more satisfaction in drain- 
ing it than in taking the same quantity of fluid from a large goblet 
which one is not allowed to empty. 

The meat diet, if not too salt, diminishes the desire for fluids very 
much as compared with a vegetable diet, for usually thirst in- 
creases in direct proportion to the amount of sugar contained in 
the blood. 

It is important not to distress the patient so much by denial that 
the nervous system suffers in consequence. 

Beverages forbidden. — As a rule, patients always do better with- 
out alcohol, and strong spirits should be absolutely interdicted as 
well as sweet and sparkling wines of every kind, all wines with 
" bouquet," especially Madeira, port, sweet sherry, Sauternes, and 
champagnes. Xo punch or liqueurs, cider, beer, ginger or sweet 
ales. Soda water with sirup is prohibited. No chocolate, unless 
especially prepared without sugar. 

Beverages allowed. — If it becomes necessary to give alcohol as a 
tonic or stimulant, an acid claret or Burgundy, hock, or still Moselle 
may be prescribed diluted with mineral water ; or a little much- 
diluted brandy, whisky, or unsweetened gin may be allowed. Weak 
brandy sometimes allays thirst better than water. Dry sherry, Cha- 
blis, and Burton bitter ale are prescribed occasionally, and the Cali- 
fornia Riesling or Zinfandel may be used. Bass's ale may be 
allowed because the sugar which it originally contained has been 
entirely converted into alcohol and carbonic acid (Flint). 

Tea, alone or with lemon. Coffee, and infusion of cocoa nibs, 
sweetened with a quarter of a grain of saccharin, are allowed. Choc- 
olate may be manufactured especially without sugar. Buttermilk 
may sometimes be given. Sour lemon or orange juice in Vichy with 
a pinch of sodium bicarbonate makes an agreeable and cooling 
draught. Saccharin may be added. In Germany acorn coffee is 
sometimes used. 

As an adjunct to the dietetic treatment, the alkaline mineral 
waters are extremely serviceable, especially those from natural wells. 
The baths and waters of Carlsbad and Neuenahr, Ems in Germany, 
and Vichy and Contrexeville in France have achieved a considerable 
reputation for the cure of diabetes, and after making all due allow- 
ance for the improvement consequent upon proper regimen, dietetic 
regulation, and systematic habits of life which are enforced at these 
spas, there seems to be special benefit derived from the waters 



682 DIET IN DISEASE 

themselves. Other waters which may be drunk are Apollinaris, 
Johannis, Saratoga Vichy, plain soda or potash water, Seltzer, the 
alkaline calcic Waukesha, or the different lithia waters. 

SPECIAL DIABETIC DIETS 

Skimmed Milk. — An exclusive diet of skimmed milk was first 
tried by Scott Donkin. At first a gill should be given every two or 
three hours, or from six to eight pints daily, to be increased up to 
twelve pints. The small amount of milk sugar contained in it is 
said to do no harm. Some authors advise the milk diet as a last 
resort, others recommend trying it at once. Senator says that the 
sugar of milk does not increase the glycosuria, and undoubtedly 
some patients are much more tolerant than others of the sugar 
of milk. 

Tyson says it is harder than any other starchy food to convert 
into glucose in the system. He recommends giving eight ounces of 
skimmed milk every two hours between 7 a. m. and 7 p. m., or more 
if necessary. If preferred, the curds and whey may be separately 
taken. 

After six weeks a gradual return to a mixed nitrogenous diet 
may be permitted. But few patients, however, can be found to ac- 
custom themselves to this diet or to endure it for more than two or 
three days. Koumiss has been successfully substituted for the 
skimmed milk. In it the milk sugar is already converted into 
alcohol. 

Buttermilk is sometimes given, and like koumiss it allays the 
thirst to some extent. The milk sugar has been converted into 
lactic acid. 

By many writers, as Dujardin-Beaumetz and Flint, milk in any 
form is prohibited, while others recommend its use in moderation 
while a rigid diet of proteid and fat must be adhered to. 

Ebstein's Diabetic Diet 

Early Breakfast. — One cup of coffee or tea (black), without milk 
and sugar. White bread toasted, thirty to fifty grammes ; or brown 
bread well buttered — butter, twenty to thirty grammes. The yolk of 
an egg, a little fat ham, or some German sausage, if required. If 
any food be needed between this meal and dinner, let it be a cup of 
broth, with the yolk of an egg. 

Dinner. — Broth, with yolk of egg or marrow (the marrow bone is 
boiled for half an hour, to solidify the marrow). Peptone may be 
added to the broth. Meat, one hundred and eighty grammes, free 
from bone, roasted, boiled, or stewed — beef, mutton, pork, veal, 
fowl, or venison (fat meat preferred). Gravies, to be made with 
cream or yolk of egg, not flour. Fish to be served with melted 



DISEASES ESPECIALLY INFLUENCED BY DIET 683 

butter. Vegetables prepared with much fat; purees of leguminous 
plants ; salads, dressed with vinegar and oil. The food should be 
well salted and spiced. After dinner, a cup of coffee or tea. 

Supper. — One cup of tea or broth. Meat (roasted), or cheese, or 
an egg, or fish, caviare. Bread, thirty to fifty grammes, with butter, 
twenty to thirty grammes. Apples, pears, and stone-bearing fruits 
are allowed in small quantities. 

Beverages. — Ebstein forbids absolutely the use of beer, limits the 
use of spirits, and allows about half a bottle of wine daily. If the 
patient can digest milk well, it is allowed in moderate doses, and 
cream is especially recommended. 

In the following diet, recommended by During, it will be noticed 
that, contrary to some other symptoms, fat is excluded as much as 
possible. 

During claims that prolonged boiling so alters the carbohydrates 
as to prevent them from being eliminated in the urine as sugar, and 
he gives his patients a diet consisting largely of rice and fruits 
which have been soaked in water and boiled for several hours. The 
details of his regimen are as follows : 

During s Diet for Diabetes 

Early Breakfast. — Milk, with a little coffee but no sugar (lime 
water, to prevent milk from souring in the stomach) ; stale white 
bread ad libitum, or, if it is not well borne, oatmeal, barley, or rice 
gruel made with water, a little salt, but no butter. 

Second Breakfast. — White bread, stale and well baked ; an egg, 
lightly boiled ; rice or oatmeal gruel, with or without milk, a break- 
fast-cupful ; or half a glass of good red wine (with water in certain 
cases). 

Dinner (taken between two and three o'clock). — Soup, with rice, 
barley, or oatmeal ; meat, roasted, two hundred and fifty grammes 
(game, ham, and smoked meats, as free from fat as possible, are 
permissible) ; no condiments, no fatty sauces; compote of dried apples, 
plums, cherries ; dried peas or white beans in some cases ; green 
vegetables, asparagus, French beans, carrots, cauliflower, cabbage 
(boiled in water with salt, not with fat or stock) ; dessert of a little 
raw fruit, apples, cherries, and one small glass of red wine diluted 
with water. 

Supper (about 7 p. m.). — Gruel of barley, oatmeal, or rice, with 
salt (but no butter), and strained, which in some cases may be made 
with milk. Ice or iced water, to relieve thirst between meals. 

Naunyn's Diet 

Naunyn divides diabetes somewhat arbitrarily into three varieties 
— mild, severe, and intermediate. For the most severe cases he 



684 DIET IN DISEASE 

gives a diet of fat meat ; the intermediate cases are treated at first 
on an exclusive diet of fat meat, then, as the sugar disappears from 
the urine, he adds eggs, milk, and a small allowance of bread to the 
diet. In mild forms he directs the use of a few green vegetables, 
salads, fruits, and other articles, unless the sugar reappears in the 
urine, when the patient is to be put back upon a rigid nitrogenous 
diet. He claims that in mild cases of diabetes patients do not re- 
quire more than from sixteen to eighteen ounces of meat a day, with 
two or three ounces of bread and six or seven ounces of vegetables. 

Hygienic Treatment. — Patients should guard themselves as far as 
possible from catching cold, and when possible should live in a 
moderately warm and temperate climate. If their surroundings 
permit, it is important to take moderate exercise and to remain in 
the open air. Flannels should be worn next to the skin in winter, 
and the body should always be kept warm, for there is less heat-pro- 
ducing power than normally. The skin should be maintained in 
good condition by frequent warm baths or hot and cold douching, 
dry rubbing, or massage. All muscular and nervous or mental 
fatigue is to be avoided. It is claimed by Kiilz that muscular exer- 
cise tends to increase the consumption of sugar or glycogen in dia- 
betes and to lessen its elimination by the kidneys. This applies to 
the more robust cases only, for in the severe type of the dis- 
ease with great emaciation much exercise becomes harmful or 
impossible. 

Medicinal Treatment. — The medicinal treatment of diabetes is 
exceedingly unsatisfactory. In a certain proportion of cases of dia- 
betes cure may result by exclusive dietetic treatment. There are 
others in which the use of medicines is found to be of some service, 
but it may be stated positively that there are no cases which are 
curable by medicines without proper dietetic treatment. 

Opium and codeia are successful in some instances in reducing 
the amount of sugar. Commencing with half-grain doses, the latter 
is to be gradually increased until ten or fifteen grains are taken in a 
day ; alkalies, such as the citrate and acetates, are also occasionally 
found beneficial. Clemen's liquor arsenici bromati has attained suc- 
cess in some hands. Digestive tonics, aromatic bitters, mineral acids, 
and cod-liver oil are frequently indicated, and strychnine and ergot 
are to be employed as vasomotor tonics when desired. They regu- 
late the arterial tension, and may reduce the quantity of urine and 
relieve the thirst. 

The nitrogenous diet is apt to excite diarrhoea, which may be 
controlled by such remedies as salol, salicylate of bismuth, or cas- 
tor oil. 

For the intense craving for food experienced by some patients, 
with a hollow, sinking feeling at the epigastrium, Roberts recom- 
mends a two- or three-grain asafcetida pill three times a day. 



diseases especially influenced by diet 685 

Rhachitis (Rickets) 

Causation. — Rickets is a disease of malnutrition. The fault may 
lie in a hereditary weakness of the digestive organs, or the influence 
of some disease, but the majority of cases are directly caused by 
improper or insufficient food. This food may be the breast milk 
of a mother or wet nurse, who is herself enfeebled by chronic dis- 
ease, by oft-repeated pregnancies, or whose mammary secretion is 
modified by dietetic errors — loss of sleep, emotional or neurotic dis- 
orders, or the milk supply may simply be insufficient from too 
long-continued nursing or the intervention of pregnancy, or some 
other factor. The poor, for reasons of economy, often suckle their 
children for too long a period — in fact, until they are two years of 
age — but even before weaning them they allow them to go to the 
table and share in the general diet of fried fish, pickles, potatoes, 
pork, raw fruits, beer, etc. Children treated in this manner are 
especially prone to develop rickets. In all doubtful cases the milk 
of the mother or nurse should be analysed before weaning, and an 
effort should be made to improve its quality. If the child is already 
weaned, the cause of the rhachitic condition may be a poorly selected 
diet, such as a patent " baby food," with insufficient fat and earthy 
salts and excess of starch. 

Rickets has been experimentally produced by Cheadle, Guerin, 
and others in young animals by depriving them of animal fats and 
earthy salts. It is caused by withholding all lime salts from the 
food (Voit), but especially calcium phosphate, and young, growing 
animals failing to receive a fresh supply absorb lime salts from 
bones already ossified for the benefit of the newer ones, and thus 
all the bones become soft. Baginsky found that this process is ex- 
aggerated in young animals by the presence of lactic acid in the 
food, and Wegner proved that phosphorus has a similar effect. 
Forster has calculated from the lime ordinarily present in milk that 
an infant four months of age receives a gramme each day. Indiges- 
tion lessens hydrochloric-acid secretion and increases lactic-acid 
formation, and lessens absorption of lime salts. 

Starchy and saccharine foods not only contain little or none of 
the necessary lime, but easily undergo lactic-acid fermentation, 
which it has just been shown intensifies the rhachitic processes. 

Bottle-fed infants are very subject to rickets, especially if the 
milk be sterilised, and breast-fed infants may become rhachitic if the 
milk is watery, of low specific gravity, too poor or too rich in fat 
or in lactose. 

Prophylaxis. — The best prophylactic against rickets is nursing 
through the first year by a healthy mother or a carefully selected 
wet nurse. It is a very common practice in this country for mothers 
to wean their babies too early, and without a physician's advice to 



686 DIET IN DISEASE 

resort to one of the much-advertised patent infant foods, with the 
result above described. 

Dietetic Treatment. — The dietetic treatment of rhachitis in a 
weanling must consist, first of all, in supplying good fresh cow's 
milk modified to resemble as closely as possible the best mother's 
milk. It is highly important that the milk should contain sufficient 
fat, and it must be modified accordingly by the addition of cream or 
oil. (See Modified Milk, p. 88.) 

If the child must be bottle fed, the milk should be carefully Pas- 
teurised in order to diminish the liability of its fermentation in the 
alimentary canal, and among the poor, who cannot afford to pur- 
chase prepared milk in this way, the milk as soon as purchased 
should be heated, and a few grains of bicarbonate of sodium may be 
added to it. A plug of previously baked cotton should be used in 
the bottle in place of a cork. When given, the milk should be 
diluted with barley water, or, if constipation is present, with oatmeal 
water. These waters are made by boiling a tablespoonful of pearl 
barley or of good oatmeal in a pint of water until the meal is com- 
pletely softened. A little salt is then added, and the mass is strained 
through a fine cloth. It is advisable also to add milk sugar. The 
proportion of milk for the diluent should be half and half for the 
first six weeks of infancy ; after this the proportion is to be gradu- 
ally increased, and when six months of age it should be given three 
parts milk and one part diluent. The quantity of milk is to be 
continuously increased, and at the ninth month it may be in the pro- 
portion of four to one, and at the end of the year dilution is no longer 
required. 

Very young infants who are fed by artificial means should not 
be given any farinaceous food. In the first two or three months of 
infant life the saliva — from deficiency in ptyalin — is incapable of 
digesting starch, and starch is also poorly digested by the pancreatic 
juice in the intestine. Starch, therefore, acts as a foreign body and 
a gastro-intestinal irritant, and passes through the alimentary canal 
unaltered. 

It is advisable in all rickety children to restrict the giving of 
farinaceous foods until some time after the period when they are 
often allowed, and, as a rule, children having rickets should not be 
fed any starchy food until after the twelfth or fourteenth month. 
They need fats much more than starches or sugars. 

There are some apparent exceptions to this where infants be- 
come seemingly robust while fed upon amylaceous foods at a very 
early period, but they are less healthy as they grow older or exhibit 
malnutrition or some constitutional weakness. Such exceptions by 
no means controvert the value of the rule in general, as above stated. 
When starchy food is given to young infants it should always be 
predigested with diastase or " malted." 



DISEASES ESPECIALLY INFLUENCED BY DIET 687 

Preparations of condensed milk which contain large quantities 
of sugar are sometimes given to infants by mothers, and they pro- 
duce a prompt increase in weight, but the appearance in these cases 
is deceptive, and the muscles and other tissues are less firm and 
strong than they should be. This is proved by the fact that chil- 
dren erroneously fed in this way succumb far more easily to various 
diseases of infancy, especially to diarrhoeal troubles, which they may 
acquire later on. After the first year a little of some malted or pre- 
digested form of starchy food may be added to the milk. 

Whenever amylaceous food is mixed with the milk it should be 
previously converted, as far as possible, into dextrin or glucose, and 
it should be added rather with the object of mechanically preventing 
the formation of coagulae of casein than with the idea of feeding the 
infant upon a substance which its digestive organs are not yet fitted 
to act upon. J. Lewis Smith says : " If a heaping teaspoonful of 
barley flour be boiled in twenty-five teaspoonfuls of water, and when 
it is lukewarm ten or fifteen drops of diastase be added to it, the 
gruel in a few minutes becomes much thinner from the digestion of 
starch, and it is a useful adjuvant to the milk employed in the 
nursery, especially for infants over the age of six months." At this 
time or later a little albuminous food in the form of mutton or 
chicken broth or the expressed juice of rare roast beef or beef- 
steak. 

After a year or fourteen months the diet should consist of cow's 
milk, cream, beef juice squeezed from a fresh steak, and broths, and 
stale bread crumbs in milk may be added. Later still, the child may 
take scraped beef or a raw beef sandwich made with thin layers or 
bread and butter with meat pulp between them. Beef tea, mutton, 
and chicken broths are good. Fresh fruit juice, especially orange 
juice, is excellent. A little sweet currant jelly added to the meat 
will improve its flavour for older children who object to taking 
it. When a year and a half old the child may be given eggs, either 
beaten with milk and sweetened or soft-cooked. If attacks of diar- 
rhoea supervene, it will be well to stop the meat broths temporarily 
and put the child for a few days on a diet of koumiss, zoolak, or 
pancreatinised milk. In some cases maltine is found to agree well 
with rhachitic children, and if diarrhoea does not exist they should 
be given pure Norwegian cod-liver oil three times a day in doses of 
a few drops for a young infant, up to a teaspoonful for a child a 
year or two old. Older children should have abundant fat, in the 
form of fresh butter on bread, or cream upon stewed fruit or baked 
apples. Fothergill wrote : " The liquid fat of fried bacon is most 
digestible, and the child should be allowed to dip its bread in it or 
have it crumbed into the fluid fat." Or it may occasionally be given 
a piece of bacon to suck. 

The fat of bone marrow might be used for the same purpose. 



688 DIET IN DISEASE 

Inunctions of two or three teaspoonfuls of olive oil may be given 
daily over the legs and abdomen. 

Rhachitic children, on account of their poor nutrition, usually 
have a deficient number of teeth or their teeth are imperfect or 
quickly decay. It is therefore important that when they have passed 
the first dentition food should always be given them in a state of 
fine subdivision, otherwise it will be bolted without mastication 
and gastro-intestinal disorder will result. Meat should be thoroughly 
hashed or pounded in a mortar, and solid meat should never be given 
the child to masticate until it is over two years of age. Potatoes 
should only be given baked in a soft and mealy form. 

Some breast-fed infants may become rickety, while others badly 
fed by artificial means may not, and the extraordinary instances of 
toleration of improper food which one constantly finds among the 
children of the ignorant poor, at times severely test one's faith in 
dietetic rules, but much allowance must be made for the constitution 
of individuals and for race characteristics. The subsequent history 
of wrongly fed children often points directly to original faults in 
diet which have affected the general nutrition of the body, although 
the immediate effect of such errors may not have been apparent. 

AIDS TO DIETETIC TREATMENT 

Rhachitic babies, as well as older children, should be weighed at 
regular intervals as an important guide for their correct feeding. 

In rickets more or less gastric catarrh is commonly present, 
which interferes with normal digestion and absorption, and appro- 
priate medicinal remedies should be employed to regulate this condi- 
tion when necessary. There is often excessive acidity in the stom- 
ach which must be neutralised by sodium bicarbonate. The hygienic 
treatment of the children in conjunction with dietetic measures is of 
the utmost importance. Rickety children must practically live out- 
doors in all seasonable weather, and it is better for them to remain 
out in fresh, cold air than to be kept at home in a damp, dark, over- 
heated, and badly ventilated tenement. They should be frequently 
bathed in order to keep the skin in as good condition as possible, 
and prevent the occurrence of skin diseases, which are a common 
accompaniment of malnutrition. They should be kept quiet and 
not worried, and if they are weak and feeble, great care should be 
exercised in handling them and in placing them in proper positions 
upon beds which are firm but not hard, in order to prevent the 
weakened bones from becoming deformed by pressure. 

Scurvy 

Causation. — Scurvy is a disease dependent upon malnutrition, 
which is customarily attributed to lack of fresh vegetables in the 



DISEASES ESPECIALLY INFLUENCED BY DIET 689 

dietary ; but this statement is somewhat vague, in that it is not ex- 
actly known which articles of diet are most liable to produce the 
disease by their absence, although many believe that the cause is 
due to deficiency of salts whose acids — citric, malic, lactic, acetic, 
and tartaric — form carbonates, but no preventive food has been 
found which is absolutely successful in all cases. At all events, it is 
a disease due to omission and not to consumption of certain foods, 
and it depends rather upon the quality than quantity of food. In 
opposition to the theory that the want of fresh vegetables acts as a 
cause of scurvy in man, the fact is stated by Lieutenant Greely 
that among the Danish Eskimos, who have a population of ten thou- 
sand, not a pound of vegetables nor a dozen pounds of bread per 
man are eaten annually, and yet they are practically free from the 
disease, and the same statement is made in regard to the most 
northern tribes of Eskimos of pure blood who were studied by Lieu- 
tenant Peary, and also in regard to the natives of the Alaskan archi- 
pelago and some tribes of North American Indians who do not 
include either vegetables or cereals in their food. It is an undoubted 
fact that the disease is much oftener present among people who 
have lived for some time in bad hygienic surroundings and in damp, 
dirty quarters, and who have been subjected to mental depression, 
monotony of occupation and diet, or excessive work and fatigue, as 
well as the abuse of alcohol. It has often been known in prisons. 
It is therefore possible for scurvy to occur in any part of the world 
among men affected by these conditions, but it is much less common 
at the present time than formerly. 

In the British arctic expedition of i^>y^-y6 over 48 per cent of 
the men suffered from scurvy, and a still larger percentage existed 
among those who were exempt from field service and outdoor life. 

When the potato crop failed in Great Britain and Ireland in 1846 
scurvy became very prevalent. In the war of the Crimea twenty- 
three thousand cases occurred among the French troops alone. 

Woodruff, referring to scurvy in the United States Army, writes : 
" If transportation is so deficient that only bacon, hard-tack, and 
coffee can be carried, actual scurvy is the result. The company 
commander must secure something else for his men. The lack of 
fresh vegetables and fresh meat is the chief fault. Why fresh things 
are needed is not known, but it is believed to be due to the fact that 
the body thus received certain salts and unknown substances neces- 
sary as stimulants or tonics to the tissues, which salts and substances 
are destroyed by the usual methods of preservation. It is not to be 
denied that men may live for many years without tasting such arti- 
cles of diet, though it is rare for a man to be denied all three — meats, 
fresh vegetables, and fresh fruits. If they are so denied they are not 
possessed of that health which permits of the highest mental and 
physical development." 



69O DIET IN DISEASE 

Scurvy contributed 15 per cent to the death rate from diseases 
in the late civil war, and it was formerly prevalent among seafaring 
men when upon long voyages, who lived upon salt pork or pickled 
meats ; but the disease is encountered much less often at the present 
time, owing to the better means of preserving foods, securing variety 
in diet, and better hygiene. The regulations of boards of trade 
usually require that antiscorbutic foods and remedies should be 
carried upon vessels, and the development of scurvy on board ship, 
unless in exceptional cases of shipwreck or in voyages prolonged 
beyond the expected limit, subjects the captains or owners to indict- 
ment for criminal negligence. The English law early required that 
lime juice should be carried on long voyages, and this formerly 
earned the nickname of " lime juicers " for British sailors. Many 
almshouses have similar regulations. 

Scurvy has been known to occur from failure of intestinal ab- 
sorption, in which case it is less easily preventable. 

Garrod holds that scurvy is caused by absence of potash, for in 
this disease the blood is deficient in potassium salts. He regards 
this fact also as an explanation of the muscular weakness which is 
a prominent feature, and observes that all good antiscorbutics — 
fresh milk, meat, lemons, and fresh vegetables — contain abundant 
potash. 

Garrod's theory is modified by Immermann, who believes that a 
temporary lack of these salts may cause trophic disorders, which may 
continue for some time after the deficiency in salts has been made 
good, and Duchek has even found that in exacerbations of symp- 
toms occurring in scurvy there may be an increased elimination 
of potash salts in the urine. The body is capable of retaining 
and reusing its various salts for a considerable time, so that with- 
drawal of the potash does not necessarily induce scurvy at once 
(Bauer). 

Northrup and Crandall investigated the causes of scurvy in a 
number of infants, and report that they find the employment of pro- 
prietary foods which for various reasons are substituted by the 
mother for fresh food is the most important cause of scurvy, and 
" even fresh milk in small proportions is not sufficient to insure per- 
fection." Their report continues : 

" The exact diet is known in thirty-three cases. We find that 
twelve of these children (36 per cent) were fed on a proprietary food 
exclusively, six (18 per cent) had received an exclusive diet of con- 
densed milk or evaporated cream, while three received a combination 
of these two foods. Over 63 per cent, therefore, were fed upon a 
diet of proprietary foods and condensed milk. Two children re- 
ceived sterilised milk exclusively, and three a weak mixture of milk 
and water. One was fed on condensed milk, one on boiled and pep- 
tonised milk, and one on barlev water. 



DISEASES ESPECIALLY INFLUENCED BY DIET 69 1 

" It is a significant fact that the country which furnishes most 
of the literature of scorbutus in children is the same which is posted 
from end to end with advertisements of proprietary foods." 

Prophylaxis. — So long as the hygienic conditions are good and 
the food is of the best quality and variety, and if proper discipline 
and regular habits of eating and sleeping are insured, scurvy may be 
prevented among soldiers and sailors, although fresh vegetables may 
not be obtainable. On American ships potatoes are always used. 
Cranberries keep well and are excellent antiscorbutic food. 

The introduction of canned and compressed vegetables in sea- 
men's rations has done much to prevent scurvy, but fresh food is 
always to be preferred to preserved food of any kind. Dried legumes 
are quite useless. For travellers in the far North, Nordenskiold 
advised the use of cloud berries (Rubus chamcemoriis) . 

Dietetic Treatment. — In mild cases of scurvy of comparatively 
short duration patients rapidly improve under proper dietetic treat- 
ment if it can be obtained. The juice of two or three limes or 
lemons, or a few fresh vegetables eaten daily, may be all that is 
necessary, and the former is one of the best preventives as well as 
curative agents. 

A. E. Wright dissents from this view, at least in regard to such 
cases as may suffer from bleeding from the gums. He claims that 
the acids, tartaric and citric, have a decided inhibitory action upon 
intravascular coagulation when given per os, and maintains, contrary 
to general experience, that in scurvy with persistent haemorrhage 
the use of fresh lemon juice tends to keep up the oozing of the 
blood. He says that the neutral citrates and tartrates do not act 
in this manner, and they should therefore be prescribed instead of 
fresh lemon juice. 

Stomatitis is often the most prominent symptom, and if the 
mouth is very tender, the gums are swollen and bleed readily, and 
the stomach is irritable, the diet must be limited to fluid or some 
solid food which requires no mastication. Beef tea, broths and 
meat soups thickened with vegetables, fresh vegetable pwces, eggs, 
and milk are recommended. To these substances the juice of two 
or three fresh oranges, limes, or lemons should be added. If the pa- 
tient is able to masticate food thoroughly and the stomach is not 
too feeble, fresh meat, baked or mashed potatoes, cabbage, sauer- 
kraut, pickles, salad, and " greens," such as water cress, fresh mus- 
tard, or radishes, may be given. The citrate of iron, vinegar, acetic 
acid, and potassium chlorate and bitartrate have all proved benefi- 
cial. During the civil war the expressed juice of sorghum was tried 
with some success. 

The treatment of scurvy in children consists first in throwing 
away all proprietary foods, and then if the disease has not pro- 
gressed too far, improvement and cure rapidly follow change to a 



6g2 DIET IN DISEASE 

normal diet of mother's milk or fresh cow's milk, expressed beef 
juice, and a little fresh orange or peach juice. 

HEMORRHAGIC PURPURA 

With regard to idiopathic purpura, which sometimes appears in 
well-nourished subjects, it has been stated that a non-stimulating 
diet, by reducing the activity of the heart, may prevent the recur- 
rence of haemorrhages. Bauer says : " Such patients should take all 
foods and drinks cool, and never in large quantities at a time ; they 
should abstain altogether from alcohol, and milk is to be recom- 
mended for its easv toleration in these cases." 



MISCELLANEOUS DISEASES 

Addison's Disease 

The aetiology of this affection is somewhat obscure, but in the 
majority of instances it results from tuberculosis or other disease 
of the adrenal bodies, perhaps associated with functional or organic 
change in the neighbouring sympathetic ganglia. 

At first no dietetic treatment is required, but in advanced cases 
there is always weakness of the digestive system, and vomiting may 
be a common symptom. There is also progressive inanition, which 
becomes extreme. The diet, therefore, must be of a light and easily 
digestible character. In some of the advanced cases the best re- 
sults are obtained from an exclusive milk diet. For others, when 
milk is not well borne, the diet should consist of beef or mutton 
broth, with eggs beaten with milk or sherry, gruels with added 
milk extracts or peptonoids, custard, rennet, milk toast. 

Nourishment should be given at short intervals, at least once 
in three hours, and the patient should be encouraged to take all 
that he can possibly digest. The intermittent vomiting may neces- 
sitate the use of nutrient enemata. Wine or spirits are usually 
required for tonic and stimulant effect ; the special variety is im- 
material. 

Osteomalacia 

The dietetic treatment of the condition of osteomalacia is sug- 
gested by what is known of its aetiology, but the results are seldom 
encouraging. It is characterised by progressive softening of the 
bones, a disease in which the salts, especially the carbonate and 
phosphate of lime, are reduced to about 30 per cent of the normal 
quantity. 

It is not definitely known in what manner these salts are dis- 
solved out of the bony structures, and excess of both lactic and 
carbonic acid have been regarded as probable solvents. It is not 



MISCELLANEOUS DISEASES 693 

proved that a deficiency of salts in the diet causes the disease, which 
has been observed in well-fed subjects. It is, however, customary 
to arrange the diet with regard to furnishing an abundance of salts 
together with such articles as milk, eggs, and meat. 

It is advisable also to prescribe cod-liver oil, either alone or in 
combination with various phosphates or hypophosphites, and this 
food proves on the whole the most serviceable. Trousseau thought 
that it cured one or two of his cases. 

It is a rare affection in its worse type, although cases of moderate 
severity are less uncommon. 

Exophthalmic Goitre 

It is only very advanced cases of exophthalmic goitre with con- 
siderable cardiac palpitation that require careful dieting. The 
indications for treatment are to support the strength and avoid 
flatulency and constipation, and any substances liable to increase 
palpitation or excite the nervous system must be withheld. Hence, 
stimulants of all kinds should be avoided. Tea, coffee, alcohol, 
condiments, and tobacco are all forbidden, as are also sugar, sweets, 
pastry, fried food, and " made dishes." 

The food should be plainly cooked, and should consist of abun- 
dant meats, milk, fats (such as cream, butter, and cod-liver oil), care- 
fully prepared cereals, fresh fruits, and green vegetables. 

Chronic Lead Poisoning 

Causation. — Chronic lead poisoning is common among all arti- 
sans or mechanics who work much with lead in any form, but espe- 
cially fyhite lead. Plumbers and house painters are therefore par- 
ticularly subject to it. It may also be acquired by eating improperly 
tinned or badly soldered canned food, although such cases are usu- 
ally acute. It is sometimes caused by using drinking water which 
has passed through new lead pipes. When present in the strength 
of only one one-hundredth of a grain to the gallon it may cause palsy. 

The cheap ale, or " four ale," as it is called, sold in London to 
the lowest classes, is sometimes kept in contact with pewter pipes 
until it contains toxic quantities of lead. 

Lead is sometimes contained in poisonous amount in beer or 
wine which has been contaminated by the metal during its careless 
manufacture. Some persons are exceedingly susceptible to lead, 
and cases are recorded of poisoning from the medical use of a few 
doses of lead and opium pills, and also from that of cosmetics con- 
taining white lead. 

Dietetic Treatment. — Chronic lead poisoning is nearly always 
accompanied by constipation, and it is highly important to over- 



694 DIET IN DISEASE 

come this difficulty by such foods as will keep the bowels actively 
open. Fresh fruits and coarse cereals (such as oatmeal, cornmeal, 
wheaten grits, Graham bread), and molasses are recommended, with 
such other foods and regulations as are given under the heading of 
the Treatment of Constipation (p. 571). 

Water should be drunk in large quantity, not only to increase 
the digestive secretions and keep the faeces moist, but to act as a 
diluent and aid in washing out the poison. 

Lemonade, acidulated with dilute sulphuric acid, fifteen drops to 
the tumblerful, or with a similar dose of aromatic sulphuric acid, is 
much in vogue as a prophylactic beverage, for it forms an insoluble 
lead sulphate from the more soluble carbonate or other salts of 
lead which may have reached the stomach by being taken with food 
or drink. This insoluble salt is not absorbed, and hence poisoning 
may be averted. 

Men employed in the manufacture of white lead or other prep- 
arations of lead believe that drinking milk freely as a beverage is 
prophylactic against poisoning, but it is doubtful whether it acts 
otherwise than as a good diuretic. 

Lead colic is sometimes benefited by lavage. 

Dietetic Complications arising from Associated 

Diseases 

There are certain diseases and conditions which are not infre- 
quently associated in the same individual, the dietetic treatment of 
each of which may be directly opposed to that of the other. Such, 
for example, are : Diabetes and chronic Bright's disease, the former 
requiring chiefly meat, the latter none ; extreme leanness and chronic 
gastric catarrh, the former condition requiring fats, starches, and 
sugars, the latter prohibiting them ; obesity and chronic albuminuria, 
the former requiring animal food, the latter none (unless it be milk) ; 
acute rheumatism and extreme anaemia, the former requiring no 
solid animal food, the latter demanding it ; intestinal dyspepsia and 
gallstones, the former benefited by a meat diet and no starches or 
vegetables, the latter doing better with opposite diet; ascites and 
chronic albuminuria, where the quantity of fluid ingested as well as 
the diet may present very opposite requirements. 

When such complications arise it is possible to compromise for a 
time upon a milk diet, this being the most natural food, and one 
which, on the whole, is capable of more universal adaptation than 
any other. In other cases, as, for example, in the first instance men- 
tioned above — of diabetes accompanied by severe Bright's disease — 
one must be governed by the patient's general condition, the gain or 
loss of body weight, the strength of pulse and muscle tone being the 
important guides for one or other system of dieting. The lesser 



SURGICAL PATIENTS AND AFTER OPERATIONS 695 

evil, whichever it may be, must naturally give way to the greater, 
and a generous mixed diet may sometimes be found to serve the 
patient better than one too much restricted by theoretical consid- 
erations. 

No subject taxes the skill and ingenuity of the dietist more se- 
verely than the treatment of such complications, when ordinary rules 
appear most contradictory. 



DIET FOR SURGICAL PATIENTS AND AFTER 
OPERATIONS, ETC. 

Food and Anaesthetics 

Preparation for the Administration of Anaesthetics. — When an 
anaesthetic, such as ether or chloroform, is to be given, care should 
be exercised that the stomach is empty, otherwise vomiting is apt to 
occur at a critical moment when the patient is weak, and, being un- 
conscious, the natural reflexes of the process, including the closure 
of the epiglottis, are not well carried out, and food is very easily 
drawn into the trachea and excites serious, if not fatal, choking. 
For this reason the patient is usually prepared for the anaesthetic by 
giving a light and easily digested breakfast, consisting solely of milk 
with, perhaps, a little farinaceous food, or a cup of coffee and a roll, 
and three or four hours later the anaesthetic may be administered 
with safety. 

Feeble patients sometimes require an ounce of brandy or whisky 
half an hour before the operation — long enough before for it to 
become absorbed. 

It is never desirable to give an anaesthetic within three hours 
after the ingestion of a full meal. It impedes anaesthetisation, be- 
sides causing the danger of vomiting and choking. In many cases 
it is better to allow five or six hours to intervene. In an emergency 
where an accident occurring shortly after a heavy meal requires the 
immediate use of anaesthesia, it may be well to give an emetic first 
for the purpose of completely unloading the stomach while the pa- 
tient is conscious. 

The instances of fatal choking from vomiting and aspirating food 
into the larynx are fortunately rare, as they are preventable, but 
they are by no means unknown. Since their occurrence is almost 
always due to negligence on the part of the anaesthetiser for not 
observing proper precautions, they are inexcusable. Ether, by some 
specific action, is more likelv than chloroform to prove irritating 
and excite vomiting while being inhaled. When retching is violent 
it may be sometimes overcome by " crowding " the anaesthetic — that 
is, by causing it to be inhaled more energetically for a moment, until 
reflex irritation is overcome. 
46 



696 DIET IN DISEASE 

Diet after Anaesthesia. — Ether, much more than chloroform, is 
apt to occasion prolonged nausea and vomiting after its adminis- 
tration has ceased, and this may last in very susceptible persons for 
a day or two. In all cases where ether is employed to produce pro- 
found narcosis, even when only used to assist physical examinations 
for diagnostic purposes, it is well that caution should be observed for 
some hours afterwards in giving food, and a light fluid diet of milk, 
beef tea, or a cup of cocoa, tea, or coffee only should be allowed 
when any tendency to nausea or vomiting exists. Under ordinary 
circumstances no food is required until the effects of the anaesthetic 
have mainly passed off, and with continued gastric irritation it is 
necessary to confine the patient to a fluid diet for twenty-four hours 
or more, and give but little of that. If the patient has been much 
exhausted by haemorrhage during the operation or by prolonged 
anaesthesia, nourishment may be sometimes given sooner, but in 
concentrated predigested form. Brandy and soda is useful under 
these conditions, and often allays gastric irritation. Very hot water 
is to be recommended for the same purpose. In cases of laparotomy 
for operations upon any part of the alimentary canal, such as ap- 
pendicitis, it may prove best to give the digestive organs entire 
physiological rest for twenty-four hours at least, but if the pa- 
tient is in need of nourishment one or two food enemata may be 
given. 

The following schedule of diet for the day may be taken as an 
example for an ordinary operation under anaesthesia : 

7 a. m. — A cup of beef tea, coffee, or cocoa, or a cup of bread 
and milk. 

11 a. m. — Anaesthesia and operation. 

3 p. :\r. — Iced milk and Vichy, beef essence, or peptonoids. If 
vomiting occurs, give hot water, or half an ounce of brandy with 
soda. 

7 p. m. — Bread and milk, or beef jelly, or cocoa and a biscuit. 
Nothing more until the next day, when, if there are no special rea- 
sons to the contrary from existing disease or complications arising 
from the operation, the patient's previous customary diet may be 
gradually resumed. 

Diet after Surgical Operations and Injuries 

Fractures, wounds, bruises, ulcers, and all surgical injuries natu- 
rally heal the sooner the better the condition of the blood. Abun- 
dant nourishing diet, properly selected in regard to its ready digesti- 
bility, is therefore indicated. Starvation promptly impoverishes the 
blood and retards all healing processes. 

Mild Cases. — In feeding surgical patients who are confined to 
bed, or who, from the nature of their injuries, are unable to exercise, 



SURGICAL PATIENTS AND AFTER OPERATIONS 697 

care should be taken that the channels for removal of waste from 
the body do not become choked and inert. In the zeal to promote 
rapid healing by a liberal diet it is quite possible to overcharge the 
blood with products of nutrition and defeat the object in view by 
burdening the liver and other organs, and inducing " biliousness." 

The patient's appetite should not be the only guide, but the con- 
dition of the tongue, the stools, and the urine should be examined to 
insure the proper assimilation of all the food taken. In the absence 
of sepsis, fever, and all affections of the alimentary canal there is 
usually no harm in allowing the full diet of animal and vegetable 
food to which the patient is normally accustomed, or, if the appetite 
flags, considerable variety in the dietary may be advantageously per- 
mitted. 

If there has been no loss of blood and no severe shock, as soon 
as an ordinary antiseptic operation is over the patient is practically 
as well as he was before it was performed. 

Cheyne says : " After operations performed aseptically there is 
no reduction of diet even for a few days. A hospital patient remains 
on full diet, and a private patient may have anything he fancies, pro- 
vided it is wholesome, and the more nutritious the food the better." 
In fact, after opening a psoas abscess or a carious joint the appetite 
soon returns and " hunger becomes the chief trouble." 

As a rule, stimulants are unnecessary if the appetite is keen, but 
otherwise beer or Burgundy or dilute whisky may be prescribed in 
moderation as an aliment, to be taken with the meals only. Hard 
drinkers who receive bad injuries, such as severe fractures, fre- 
quently develop delirium tremens in the course of a few days, and 
this may occur even when they have not been indulging in stimu- 
lants for some weeks previously. In such cases it may become 
necessary to allow a certain quantity of alcoholic stimulation at 
stated intervals between meals, in order to tide them over an emer- 
gency which threatens an immediately fatal result, trusting to reduce 
the quantity as the delirium subsides. 

Severe Cases. — If severe pain has preceded an operation, if the 
operation has been prolonged, or if there has been much shock, 
even under anaesthesia, the diet must be supervised with great care. 
Pain is a strong depressant, and after severe shock rest and stimula- 
tion is usually more desirable than food. Positive harm results from 
overfeeding. Black coffee is very serviceable for such cases or 
whenever there is lack of nerve energy, and it may be appropriate to 
keep the patient for three or four days upon a diet of milk or pan- 
creatinised milk. Broths, meat extracts, and beaten eggs may be 
added when the stomach regains its tone. If nausea, anorexia, or 
disgust for food exists, or if there is much distention of the stomach, 
it is unwise to urge food upon the patient. It is better to utilise the 
rectum in such cases, and coffee, pancreatinised milk, egg albumin, 



698 DIET IN DISEASE 

and alcohol are to be given in enemata. Opium or other necessary 
medication may be added. 

If extensive loss of blood has occurred, the volume of fluid should 
be replaced in the body as soon as possible, and liquid food is 
needed, such as milk, beef broths, peptonoids, and brandy or whisky, 
if the stomach retains them. Salt-water injections, or in severe 
cases hypodermic injections of saline solutions, help restore the lost 
fluid to the blood and improve vascular tone. 

Diet after Laparotomy, Ovariotomy, etc. 

After all operations involving opening the peritoneal cavity com- 
plete rest of the stomach is necessary for at least four or six hours, 
and not infrequently for two or three days. Food and stimulants 
may be given by enemata (p. 408). If fed per os for the first three 
days not over a tablespoonful of pancreatinised milk or milk with 
lime water or barley water should be allowed once in two or three 
hours. Later the quantity may be increased and the intervals dimin- 
ished, and beef tea, beef peptonoids, and egg albumin may be added. 

In these cases the duration of anaesthesia has usually been pro- 
longed, and the shock is considerable. The danger from the occur- 
rence of vomiting, malfermentation of food, and flatulent distention 
of the abdomen is far worse than that of inanition from abstinence. 
It is well also to precede the operation by a day or two of dieting 
in order to lessen the bulk of intestinal waste matter. To this end 
the diet should, when possible, consist chiefly of lean meat and dry 
toast, vegetables and especially sweets being avoided. 

After wounds and operations affecting the stomach or intestines 
no food at all should be given by the mouth. Nothing but a little 
cracked ice should be so administered, and all nourishment must be 
supplied for several days by the rectum. The return to mouth feed- 
ing must be made very slowly and cautiously by at first giving not 
over one or two tablespoonfuls of pancreatinised milk or beef juice 
at a time. 

There is often much thirst following operations involving the 
peritonaeum, which is relieved more by hot fluids than by ice, which 
sometimes irritates the throat and increases the desire for drink. If 
there is danger of all fluids exciting emesis, a salt-water enema once 
in three or four hours will alleviate thirst (p. 404). 

Diet in Surgical Inflammations, Sepsis, etc. 

The diet in surgical inflammatory conditions was formerly re- 
duced to a minimum, with the idea that the healing process would 
be more sure if the stimulating influence of food was removed, and 
that the inflammation, like an infectious fever, should be " starved 
out." The diet absoluc, as the French surgeons of the first half of 



SURGICAL PATIENTS AND AFTER OPERATIONS 699 

this century termed it, meant virtual starvation, barley water, arrow- 
root water, or toast water being all that was allowed. With im- 
provement in feeding fevers came a change in the diet of inflamma- 
tory conditions, and it was recognised that the waste of tissue mate- 
rial and the expenditure of force in the evolution of heat must be 
replenished by nutritious food. No one to-day starves pneumonia, 
nor yet does an intense local inflammation of a joint demand that 
the patient should have solid meat meals, but there is an appropriate 
mean to be observed between overfeeding and starvation. After 
operations inflammation will not be avoided by starving, and the 
patient's strength must rather be supported by easily assimilable 
food. In acute inflammatory conditions tissue waste is rapid and 
appetite and digestive power are lessened. 

In severe cases a diet of milk, diluted by one third or one half 
with Vichy or Seltzer water, may be given, four ounces every hour 
and a half or six ounces every two hours. Other articles should be 
added, such as expressed beef juice or beef peptonoids. These sub- 
stances may at first be given alone, and then added to strong beef, 
mutton, or chicken broth. Gruels of arrowroot or oatmeal, raw 
eggs alone, or beaten and added to sherry or brandy, custard, milk 
puddings, and beef jelly are all recommended. 

When improvement occurs, a light convalescent diet may be pre- 
scribed, such as that found on p. 435. Acidulated drinks, sour 
lemonade, oatmeal or barley water, and effervescing waters may be 
used to relieve thirst. 

In mild cases, and in the early stages of many inflammations, 
alcohol is not required, but if at any time the pulse becomes feeble, 
the tongue grows dry, or delirium supervenes, stimulants, such as 
whisky or brandy, should be freely given. Elderly people and those 
who have been previously reduced by wasting diseases require 
earlier stimulation in the form both of meat extracts or meat juice 
and alcohol. From four to six ounces or half a pint of liquor may 
be prescribed in twenty-four hours, according to its effect on the 
pulse. In the milder inflammations, especially those of tubercular 
joints, malt liquors may be of service. A good strong toddy at 
night may be made to take the place of opium. 

Burns, when severe or extensive, require prompt and energetic 
stimulation. In bad cases a pint and a half of brandy must be given 
in twenty-four hours. 

In chronic surgical diseases, attended by the formation of pus, 
fresh green vegetables and fresh fruits are often serviceable, both 
for their antiscorbutic and laxative effect. Lemonade, oranges, 
baked apples, or stewed prunes are recommended. Fats are also 
especially needed, and butter, cream, olive oil, or cod-liver oil should 
be added liberally to the diet when the patient is able to digest foods 
of this class. 



PART IX 
RATIONS, DIETARIES 



ARMY AND NAVY DIETS 

The food furnished to soldiers and sailors, both in time of peace 
and war, is more accurately weighed and measured, and its effects 
are more accurately studied, for economic reasons than is the diet of 
any other class of men, even including hospital patients. While 
seeking to furnish wholesome variety it is necessary to keep the 
quantity of food as uniform as possible, and this may be done by 
substitution of articles the nutrient power of which is closely re- 
lated ; thus eggs may be occasionally substituted for milk, or peas 
or beans may be served for a change instead of cereals. 

The United States Army Rations 

A " ration " is technically the total quantity of food issued for 
one man for twenty-four hours in accordance with law, and not, as 
often supposed, the allowance for one meal. The original princi- 
ples upon which military rations have been selected are thus sum- 
marised by Major Charles E. Woodruff, Surgeon, U. S. A. : 

" i. Economy is essential. 

" 2. The food must be the product of the country at large, neither 
a specially prepared article nor the output of a few manufacturers. 

" 3. The articles must be easily preserved in all climates by the 
most ignorant men. 

" 4. The articles must be easily transported and capable of the 
roughest handling during transit. 

" 5. The ration is intended for the strongest and most robust 
men in the nation. 

" 6. It must be approximate to the food used by the nation at 
large, so that there will be no rapid change of diet on enlistment 
that would impair the health. 

" For these reasons the soldier's ration has always been simple 
and dry." 

Some of these principles, as the author quoted points out, are 
radically wrong. It is false economy to furnish too cheap or mo- 
notonous diet, which only courts disease and swells the pension roll. 

After the Revolutionary War, in 1785, the army ration consisted 
of one pound of beef, one pound of bread, and one gill of rum. This 
700 



ARMY AND NAVY DIETS 



70I 



was quite insufficient, and was subsequently increased (Woodruff). 
During that war, in addition to the above ration, the soldier received 
one pint of milk, a little molasses, and a few dried vegetables, with a 
quart of beer in place of rum. 

The present United States army ration costs less than fifteen 
cents. The German soldier is expected to eke out his peace ration 
by supplies contributed from his home, and the French and English 
soldier by contributions from his pay, but in the United States the 
men usually serve so far from home that this system is neither eco- 
nomical nor desirable. Moreover, with the improvements in can- 
ning and other methods of food preservation and condensation, it is 
no longer necessary for the ration to be the product of the surround- 
ing country. The importance of an adjustable army ration is appre- 
ciated when it is considered that within the limits of service in the 
territory owned by the United States may be found a temperature 
range of 150 F. Diet suitable for Alaska is wholly unfit for Manila. 

UNITED STATES ARMY RATIONS 
1. For Troops in Garrison {Garrison Ration, igoi) 



Meat components, 



Bread components 



Vegetable compo- 
nents 



Dried (or evapo- 
rated) fruit com- 
ponents 



Coffee and sugar 
components. . . . 

Seasoning compo- 
nents 



STANDARD ARTICLES. 



Kinds. 



Fresh beef. 



Flour 



C Beans. 



^Potatoes, 



Prunes 



Coffee, green, 
Sugar , 



Soap and candle 
components. . . . [ 



( Vinegar 

]salt 

Pepper, black 

Soap 

Candles 



Quantities. 



20 ounces. 



ounces. . . 



2f ounces. . 



16 ounces. -{ 



if ounce.. 

if ounce. . 
375- ounces. 



tfr 



rill 



If ounce. 
Yji ounce. 
£f ounce. 
- 2 *V ounce. 



SUBSTITUTIVE ARTICLES. 



Kinds. 



Fresh mutton 

Bacon 

Canned meat 

Dried fish 

Pickled fish 

Canned fish 

Soft bread 

Hard bread 

Cornmeal 

Peas 

Rice 

Hominy 

Potatoes 

Onions 

Potatoes 

Canned tomatoes. . . 

Potatoes 

Fresh vegetables, 

not canned 

Desiccated vegetables 

1 Apples 

1 Peaches 



Roasted and ground 
Tea, black or green. 



Vinegar 

Cucumber pickles, 



Quantities. 



20 ounces. 
12 ounces. 
16 ounces. 
14 ounces. 
18 ounces. 
16 ounces. 
18 ounces. 
16 ounces. 
20 ounces. 
2§ ounces, 
if ounce, 
if ounce. 
I2f ounces. 
3^ ounces. 
I2f ounces. 
2,5 ounces, 
ill ounces. 



4f ounces. 
25- ounces. 

if ounce, 
if ounce. 

i-is- ounce. 
^ ounce. 



A gill. 
A gill- 



yo2 



RATIONS, DIETARIES 



2. For Troops in the Field in Active Campaign {Field Ration) 



Meat components 
Bread components 



Vegetable compo- 
nents 



Fruit component. 

Coffee and sugar 
components. . . . 

Seasoning compo- 
nents 



Soap and candle 
components. . . . 



STANDARD ARTICLES. 



Kinds. 



Fresh beef. 
c Flour 



Baking powder 
Beans 



Potatoes. 



Jam 

( Coffee, roasted 
■< and ground. 
( Sugar 



( Vinegar 

ISalt 

( Pepper, black. 

j Soap 

( Candles 



Quantities. 



20 ounces. . 

18 ounces. . , 

•gf ounce.. . . 
2f ounces. . . 

r 

16 ounces. •{ 

I 
if ounce. 

1^5- ounce. . . 
33- ounces. 



£f ounce. 
2^5 ounce. 
£§ ounce. 
-£g ounce. 



SUBSTITUTIVE ARTICLES. 



Kinds 



Fresh mutton 

Canned meat 

Bacon 

Soft bread 

Hard bread 

Hops 

Dried or compressed 
yeast 

Rice 

( Potatoes 

\ Onions 

Desiccated potatoes. 

Desiccated potatoes. 

Desiccated onions. . 
\ Desiccated potatoes. 
1 Canned tomatoes. . . 



Tea, black or green, 

Vinegar 

Cucumber pickles. . 



Quantities. 



20 ounces. 
16 ounces. 
12 ounces. 
18 ounces. 
16 ounces. 
t^t ounce. 



sV ounce, 
if ounce. 
I2|- ounces. 
3^- ounces. 
2j ounces, 
iff ounce. 
y§- ounce, 
iff ounce. 
3-5- ounces. 



2% ounce 

A gill. 
A gill. 



j. For Troops when Traveling otherwise than by Marching or when for 
Short Periods they are separated from Cooking Facilities ( Travel Ration) 



STANDARD ARTICLES. 


SUBSTITUTIVE ARTICLES. 


Kinds. 


Quantities per 
100 rations. 


Kinds. 


Quantities per 
100 rations. 


Soft bread 


112^ pounds. . 
75 pounds.. 
25 pounds. 
50 pounds. 
8 pounds. 
15 pounds. 




100 pounds. 
75 pounds. 


Canned corned beef. 


Corned beef hash. . . . 


Baked beans 


Canned tomatoes 




Coffee, roasted and ground. . . 
Sugar 









The above (3) has the following composition (approximately) 





Protein. 


Fats. 


Carbo- 
hydrates. 


Calories. 


/-. ( Maximum 


I50 
I20 


I70 
94 


417 
380 


3,900 
2,900 


Grammes. K,. . 

1 Minimum 




Mean 


135 


132 


400 


3.400 





" This ration is insufficient for active men, being equivalent to 
the food of men of sedentary habits. The protein is the only ingre- 



ARMY AND NAVY DIETS 703 

dient in nearly the proper amount, and this arises from the meats 
and beans " (Woodruff). 

Although considerable latitude is allowed in the use of substitute 
foods or variants in the diet, in actual practice army officials and 
cooks commonly follow routine methods. In commenting upon the 
importance of adapting our army ration to the needs of the tropics, 
Major Kean says : 

" Fish is largely eaten by all tropical races near the source of 
supply, and is undoubtedly less stimulating and more easily digested 
than butcher's meats. For this cause, and to secure variety, fresh 
fish, where obtainable, should be used twice a week, no savings 
being permitted. 

" The issue of the meat components at Columbia Barracks, 
Cuba, for 185 consecutive days in 1900 was as follows : 

Fresh beef 124 days. 

Mutton none. 

Bacon 47 days. 

Fresh fish 1 day. 

Other issues 13 days. 

" Which shows well the monotony of the issue, the only impor- 
tant variant being the undesirable bacon. A certainly more desir- 
able issue, and one apparently permissible according to the paper 
ration, would have been, for example, somewhat as follows : 

Fresh beef 100 days. 

Fresh mutton 37 days. 

Fresh fish 38 days. 

Other issues 10 days. 

" A saving of two fifths of the fresh meat being authorised. As 
fresh fish is quite cheap at Havana, the difference in cost would 
have been immaterial." 

For the tropics this ration contains twice too much salt pork 
and fresh meat and too few fresh vegetables. The white beans 
especially cause diarrhoea, and the canned tomatoes are liable to fer- 
ment. The tropical red beans are less irritating than the domestic 
white beans. Red beans and hominy are the staple of the Mexican 
army diet (Seaman). 

Major Kean states (U. S. Surgeon General's Report for 1900) 
that : " A tropical dietary, as compared with one suited to a colder 
climate, should have less fat and more carbohydrates, less stimulating 
proteids in the form of meat, a greater variety of diet both of meats 
and of carbohydrates in the form of fresh vegetables and fruits, and, 
lastly, a fairly liberal supply of ice. His argument for the substitu- 
tion of carbohydrates for fats is that the digestion is weakened in 
hot climates and the liver is inclined to torpidity, while ingested fats 



704 RATIONS, DIETARIES 

are prone to split up into butyric, caproic, and other irritating acids, 
which the diminished secretion of the liver is unable to neutralise. 
As intestinal digestion cannot proceed in the presence of acidity, the 
condition known as biliousness is established, with putrefaction of 
the intestinal contents and the production of various harmful alka- 
loidal substances. A catarrhal inflammation of the bowel results, 
with diarrhoea, which is at first of advantage in eliminating the 
harmful substances, but which under the continued irritation of un- 
suitable diet is liable to continue and become aggravated. As to a 
lessened use of meat, he cites the dietary customs of the inhabitants 
of hot climates, who get their proteids less from meat than from the 
leguminosse. The appetite is lessened by long and continued heat 
and becomes capricious. It craves variety, especially in vegetables 
and fruits, and these he claims cannot be had on the basis of our 
present ration. The need of ice to furnish a cool drinking water and 
to preserve the perishable constituents of the ration is regarded as 
obvious." 

Munson, in an essay which was awarded the prize of the Military 
Service Institute for 1900, says : " It is true that the sugars and 
starches should be slightly augmented, but their increase is small 
when compared with the considerable reduction of nitrogenous and 
fatty matter which is proposed." 

It is poor economy to make the change too radical between the 
garrison and field ration, for in the latter service men are exposed to 
conditions of hardship and fatigue which demand a more nutritious 
and varied diet than they obtain in barracks. It is well known 
that the history of all prolonged wars presents a far greater death 
rate from disease than from the wounds of battle, and much of the 
former is caused by improper or insufficient food. The active soldier 
should have meat three times a day. 

When leading a comparatively inactive post life the ration 
may prove too large — i. e., the food furnishes more energy than 
the body needs, but there is not always enough variety. Any 
excess of food is then sold to a co-operative store, and the money 
thus acquired is expended for a few luxuries to stimulate the 
appetite. 

The most concentrated ration which it is practical for soldiers to 
carry in the field consists of bacon, hard-tack, and coffee. This is a 
scorbutic diet, and always produces constipation. To obviate this it 
is now customary to carry desiccated fruits, concentrated by drying, 
and which are not spoiled by extremes of temperature. Chocolate 
has been added to the new U. S. army emergency ration, as it has 
been in Austria and Russia. 



ARMY AND NAVY DIETS 



705 



Uncooked Food of Garrison Ration for Ten Days. Weights in Pounds. 
Daily Average, 440.4 Men (Woodruff) 



Bacon 

Beans 

Pork 

Sugar, brown . . . 

Flour 

Beef 

Potatoes 

Onions 

Oatmeal 

Cornmeal 

Apples, canned . 
Apples, dried . . . 
Tapioca (26) and 
Cornstarch ( 13) 

Butter 

Sirup 

Lard 

Rice 

Corn, canned. . . 
Tomatoes, can'd. 
Macaroni (51) 

and vermicelli 

(ii) 

Milk, fresh, lbs. . 
Milk, condensed, 

lbs 

Cheese 

Prunes 

Cabbage and 

sauerkraut 

Ham 

Apricots 

Barley 

Peas 

Raisins 

Chocolate 



Gross 
weight. 



Waste 



273* 
428*1 

343* 

73i 

4,379 

5,025 

5,n6 

700 

44 

85 

10 

183 

39 

58 
165 
107! 

26 

63 
332 



52* 
3i 

3i 
ioi 

35 

250 

32 

20 
5 
4* 

H I 
3 



3i 



I26i 

1,131 

1,386 

150 



Net 
,-eisrht 



270 
428* 
3I2t 
731 

4 ,2 5 2t 
3,894 
3,730 
550 

44 
85 
10 

183 

39 

58 

165 

107* 

26 

63 

332 



52i 
3i 

3i 

10 

15 

200 

28 

20 

5 

4i 
10 



Water. 



54.00 

54-05 

37.85 

21.93 

53I-56 

2, 196 . 70 

2,943.00 

481.80 

3-34 
12.75 

8.32 
46.85 

0.78 

6.09 

70.60 

12.90 

3-22 

51.22 

318.72 



6.88 
25.61 

7-75 
3-50 
10.00 

182.00 
11.63 
i3-5o 



o.55 
6.45 
0.48 



Totals 18,598 2,908!- 15,689? 7,120.50 1,413.21 1,657.175,343.66154.8219,446,960 



Protein. 



21.60 

99.10 

2. 



467.78 
682.97 

78.33 
7.70 
6.65 

7- 

0.02 

1.65 



0.58 



0.65 
1.92 
1.77 
2.66 



4-73 
1.58 

5-27 
3.30 
o.75 

4.20 
4.68 
0.40 
0.65 
1.20 
0.05 
0.60 



Fats. 



187.65 

8-57 

259.00 



46.78 
978.38 
3-73 
1.65 
3.13 
3-23 
0.04 
3.30 



49.30 



89.66 
0.14 
0.70 
i-33 



0.15 
1.50 



3-4i 
2.20 



0.60 
11.00 



0.14 
0.08 



1.50 



Carbo- 
hydrates, 



253-8o 



705.42 
3,185.12 



667.67 

55-55 
30.01 
60.01 

i-59 
130.85 

38.14 

0.29 

90.60 



20.65 
8.32 
8.30 



40.32 
2.00 

13.64 
0.50 
4.00. 

11.00 



6.00 
3.80 
2-54 
3-50 
0.30 



Salts. 



6.75 
13.29 

13 14 

3-66 

21.26 

35-95 

37-30 

3-30 

o. 

1. 19 

0.03 

2.57 

0.08 
1.74 
3.80 
4-30 
0.14 
0.38 
1. 00 



0.42 
0.31 

o.93 
0.50 

0.25 

2.20 
0.76 
0.12 
0.15 
0.12 
0.08 
0.12 



Calories. 



831,600 
691,228 

J ,097,753 
1,312,081 
6,991,110 
5,409,392 
1,398,750 

123,750 
81,400 

139,825 
3,150 

259,494 

70,980 
209,670 
168,795 

383,775 
42,380 

2i,735 
26,560 



73,8i5 
12,552 



49,442 

16,000 

3,500 



31,000 

54,880 

9,200 
9,000 

7,043 
6,153 
7,950 





Pounds. 


Grammes. 


Daily average 
per man .... 

Counting flour as 
bread, amount 
eaten is 4 lbs. 
per man. Per 
cent of amount 
eaten 


4.22 


3.56 

85^ 


0.66 
15** 


733 
45 


145 

9 


171 
11 


550 
34 


16 


4,416 









The usual army-ration tables are misleading in that they omit to 
account for the consumption of considerable accessory food, which 
is purchased by the soldier in addition to the portion he receives as 
fixed by law. Major Woodruff has taken pains to carefully com- 
pute the nutrient value of the entire food eaten by the men of his 
garrison at Fort Assinniboine, Montana, during a period of ten days. 
His table, taken from the Journal of the American Medical Associa- 
tion, December 3, 1892, p. 651, is above. 



706 



RATIONS, DIETARIES 



Additional Articles consumed 





Daily per 
man. 


Allowance. 




338 lb. green coffee 

8 lb. tea 


1.23 oz. 1 .60 oz. or 
0.03 oz. 0.32 oz. 

0. 14 gill 0.32 gill 
0.46 oz. 0.64 oz. 

0.036 oz. O.04 oz. 

f Though containing m 
■i composition is unkr 
[ man is very small. 




20 gall, vinegar } 

128 lb. salt ) 


f Allowance is large, to allow of 
J making a saving to be used 
] in making sauerkraut and 
(_ pickles in the fall. 


11 bottles flavouring ext'ts. 

3 lb. mustard. 

24 lb. baking powder. 
6 lb. currants. 
5 gall, pickles. 

4 kegs pickled pigs' feet . . 


uch energy, it is omitted because 
lown, and the actual amount per 



EMERGENCY RATIONS 

For scouting parties, troops under forced marching, or under 
any circumstances which make the supply of the ordinary ration 
impossible, an emergency ration for temporary service is necessary. 
The time-honoured food for this purpose consists of bacon, hard- 
tack, and coffee, sometimes with addition of a little ground peas 
or beans. 

In the autumn of 1900 an emergency ration was tested in Idaho 
upon a troop of cavalry. The ration contained in an elliptical can 
eight inches long weighed one pound and contained three cakes of 
sweet chocolate (four ounces) and three of a meat (four ounces) and 
grain compound (eight ounces) having a taste not unlike parched 
corn. The latter can be eaten uncooked, or as porridge or fried 
mush. Salt and pepper accompanies the cakes. The ration may be 
eaten dry, as a soup or porridge, or fried. The test proved success- 
ful. The details of preparation of this ration, furnished me by Colo- 
nel Alfred A. Woodhull, U. S. A., are as follows: 

The chocolate component consists of equal weights of pure 
chocolate and pure sugar molded into cakes of one and one third 
ounces each. Three of these go into the day's ration. 

The bread and meat component consists of: (1) Fresh lean beef 
free from visible fat and sinew, ground in a meat-grinder and desic- 
cated so as to contain five per cent or less of moisture, the heat never 
being allowed to cook it in the slightest degree. The dried product 
is then reduced to powder and carefully sifted through a fine-meshed 
sieve, the resulting flour being the meat component. 

(2) Cooked kiln-dried wheat, the outer bran removed, is parched 
and then ground to a coarse powder. This yields the bread com- 
ponent. Sixteen parts of the meat, thirty-two parts of the bread, 
and one part of common salt, all by weight are thoroughly mixed 



ARMY AND NAVY DIETS 



707 



in such small quantities as to be entirely homogeneous and com- 
pressed into four-ounce cakes. Three of these go into the day's ra- 
tion. The bread and meat may be eaten dry, or be stirred in cold 
water and eaten ; or one cake may be boiled for five minutes in three 
pints of water and seasoned to taste ; or one cake may be boiled for 
five minutes in one pint of water to make a thick porridge and be 
eaten hot or cold. When cold it may be sliced, and if fat is available 
may be fried. 

Three fourths of an ounce of fine salt and one gramme of black 
pepper are in the can for seasoning. 

" This ration is calculated to subsist a man for one day, maintain- 
ing his full strength and vigour." As it amounts to a pound of 
water-free food perhaps it will do it if not depended upon too long. 



Foreign Army Rations 

Soldiers Daily Peace Ration, in Ounces Avoirdupois 





British 
(average). 


French. 


Austrian. 


German. 


Bread 


24.O 
I2.0 


35-2 
IO.6 


3I.O 

9 .8 7 


26.50 

j 8.81 (larger ration) 
\ 3 . 80 (smaller ration) 


Meat (uncooked) 



It is apparent from this table that the French, Austrian, and Ger- 
man rations all contain more bread and less meat than the English. 
In addition, the men have potatoes and other vegetables, green or 
dried, besides sugar, coffee, salt, etc., which are either issued with 
the ration or purchased with a special allowance of pay, so that the 
above figures, which apply to only two articles, fall somewhat short 
of the actual food consumed. For example : The British soldier re- 
ceives a total of sixty-five ounces of solid food against the French 
soldier's fifty-one ounces (Parkes) ; but many of them are under- 
grown men, being several years under twenty-five, up to which 
period the formation of the bones is not always complete. The Brit- 
ish army ration contains from four to six ounces less meat than the 
United States ration, and 4.2 ounces more rice. 

In England the daily ration of the soldier on home service con- 
sists of one pound of bread (twenty-four ounces is given above as 
the average for foreign service) and three quarters of a pound of 
meat, which is supplemented by an allowance of about fivepence a 
day to be expended on minor articles of diet, green vegetables, milk, 
sugar, and beverages. 

In the French army legumes form an important element of the 
ration, to some extent replacing animal food, and many experi- 
ments have been made with the German army in regard to the intro- 
duction of vegetable food, especially pea meal, which is rich in nitro- 
genous material. 



708 



RATIONS, DIETARIES 



In France and Holland during active service in the field, in 
manoeuvres, or in battle the diet is materially increased. Experi- 
ments made in 1897 upon an Austrian regiment in garrison showed 
an average gain in weight of 6.6 pounds per man in three months 
upon a steady daily allowance of protein 120 grammes, fat 56 
grammes, carbohydrates 500 grammes (J. Schorr). 

The larger ration of the German army, issued during the marches 
or manoeuvres, contains about five ounces more meat and sev- 
eral ounces more vegetable food, and in war thirteen ounces of 
meat are given. Bacon, salt meat, and rice are also supplied. 
The German army ration for the tropics contains 5.33 ounces 
of fresh meat, or 4.4 ounces of bacon and seventy-nine ounces of 
vegetables. 

All the chief armies of Continental Europe issue a wine ration in 
war times. To the French war ration are added nine ounces of wine 
or two and a quarter ounces of brandy per diem. 

Munson advocates the use of a tropical army ration comprising 
fresh fruit, soft bread, potatoes, rice, tomatoes, dried fruits, sugar, 
and protein limited to one hundred grammes. 



Nation. 



I. England 



2. Spain . . . 



3. Austria. 



Ration. 



1. Home 

2. Foreign station, or 

under canvas at 
home 

3. March 



Gnis. 



93 



in 
120 



4. War -!M aX,!l65 

\ Mm., 133 



Sometimes 2 oz. rum 



1. Peace 



j Max. I 147 
I Min.! 120 



2. War, on march ( Max, 
or in the field { Min. 
Sometimes 1.7 oz. 
brandy 



1. Peace 

2. War.. 



131 
113 



155 
165 



Gms. 
6l 



128 
92 



125 
130 



U 



Gms. 
244 



244 

327 



425 
425 



588 
5OO 

522 

485 



504 
504 



1,938 



2,175 
2,550 



3,634 
3,204 

175 

3,729 
3,421 

3,327 
2,550 

I50 



3,865 
3,952 



Remarks. 



This is starvation diet, 
and the extra food 
needed for health is 
purchased and charged 
against the soldier 
(about six cents a day), 
increasing, perhaps 
doubling, the food 
value. 

Can be greatly changed 
to suit climate. 

Sufficient for such a mild 
climate and very mod- 
erate work. 

Varies enormously ac- 
cording to class of ra- 
tions issued. Very 
many extra allowances 
of money for food. 

This is augmented by 
four cents per day for 
vegetables, etc. On 
the march a limited 
emergency ration is 
used. The war ration 
is so insufficient that 
commanders of armies 
or smaller forces may 
change, supplement, or 
even double it. 



ARMY AND NAVY DIETS 



709 



Nation. 



Ration. 



4. Italy.. 



5. Germany 



6. United 
States, 



7. France. . 



Russia 



1. Garrison 

2. Camp 

3. Marching 

Usually wine added. 



Gms. 

Ill 
115 
125 



I. Small rations 
and portions 
in garrison 
and canton- 
ments 



Max 
Min 



2. Large rations] 

and portions j , , 
on march or ^ax. 
in manceu- | 
vres J 

3. Field Ijjax. 

3 I Min. 

Commanding general 
may add 33- oz. 

whisky 

Max. 
in 
Max 
Min 
Ave 

Food actually eaten "] 
in cold climate, j 
moderate work, { 
including all ex- 
tras from gardens 
and purchases . . . 



, -r> , ( Ma 

• B y law ]m« 



2. Usually in 
field(bylaw). 



War 



Max. 
Min. 
Add 2tV oz. brandy. 



1. Peace. 



j Max. 
• ' j Min. 
Add 3 oz. wine 



2. W; 



Max. 
Min. 



Add 4-3- oz. wine. 



150 
99 



172 

138 



195 

78 



183 

105 

106 

64 

85 



155 



183 
146 



233 
165 



174 
149 



Gms, 

130 
133 
143 



260 
103 
320 
240 

280 



180 



300 
127 



114 

65 



Gms. 

60O 
600 
600 



703 
502 



915 
644 



703 

515 



621 
500 
540 
460 
500 



597 



690 
520 



976 
746 



805 
640 



4,129 

4,163 

4.307 

250 



3,947 
2,827 



4,961 
3,744 

4,786 
3,413 



268 
5,368 
3,712 
5,166 
4,722 
5,ooo 



4,907 



5,455 

4,oi5 

184 



5,884 

4,45o 

223 



4,583 

3,307 

362 



Remarks. 



Allowances of one fifth 
cent per day for condi- 
ments ; occasional extra 
money allowances for 
food. Excepting the 
protein, it is a very lib- 
eral diet for such a mild 
country. 

"| This is what the govern- 
ment may supply. Usu- 
ally the soldier feeds 
himself and is given 

)- seven cents a day, or 
more, to reimburse him- 
self. Food eaten is 
more than this defi- 
cient diet. 



") Maxima due to fats if all 

; the bacon is used and 

y no meat. The whole 

ration is supposed to be 

J supplied and eaten. 



Peace ration not stated. 
It is purchased as need- 
ed and charged against 
soldier. War ration is 
subject to great aug- 
mentation for increased 
work or cold climate. 
The commanding offi- 
cer can augment ration 
on the march. 
") Also allowed money to 
buy one half to one and 
one half ounces extra 
meat, and one to one 
and one half cents for 
vegetables, salt, butter, 
lard, and groceries. 

Extra meat and spirits 
may be ordered by the 
commander in chief. 



710 



RATIONS, DIETARIES 



The foregoing comparative table of various national army rations 
was published by Major Charles E. Woodruff, M. D., U. S. A., in 
the New York Medical Record (vol. lv, No. 20, 1899). 

As stated by Major Woodruff, the United States is the only 
nation in the world that in time of peace pretends to supply the en- 
tire ration. Soldiers living in densely populated European coun- 
tries supplement their rations by local purchases from a mess fund 
or, as in Germany, from supplies from his home. In Austria bread 
alone is furnished as a peace ration, other food being purchased 
from a money allowance. At remote frontier posts in the United 
States a variety of local purchases is frequently unobtainable, and 
hence the attempt to supply the whole ration in kind. 



Navy Rations 

From Table A, showing the Different U. S. Navy Rations and their Compo- 
nent Parts, as established by Law, with the Substitutes legally allowed for 



each Article 



Allowance for General Use 



Rations as composed 


EITHER 


OF THE FOLLOWING — 


by Law. 


Specified by law. 


Substitutes authorised by law. 


Ration No. I 


I lb. salt pork. 

\ pt. beans or peas. 




i£ lb. fresh meat, or 
£ lb. preserved meat. 
Vegetables of equal value, or 
\ lb. rice. 


Ration No. 2 

Ration No. 3 


1 lb. salt beef. 
| lb. flour. 

2 oz. dried fruit. 

£ lb. preserved meat. 
\ lb. rice. 
2 oz. butter. 

1 oz. desiccated mixed 
tables. 


vege- 


l£ lb. fresh meat, or 

£ lb. preserved meat. 

Vegetables of equal value. 

No substitute. 

4 pt. beans or peas. 

No substitute. 

6 oz. canned vegetables. 


Ration No. 4 


£ lb. preserved meat. 

2 oz. butter. 

6 oz. desiccated tomatoes 




No substitute. 
No substitute. 
6 oz. canned tomatoes. 




Weekly Allowance 






\ pt. pickles. 
\ pt. molasses. 
\ pt. vinegar. 








Daily Allowance 






14 oz. biscuit. 




1 lb. soft bread. 
1 lb. flour. 
\ lb. rice. 




\ oz. tea. 




2 oz. coffee. 
2 oz. cocoa. 




4 oz. sugar. 




For coffee and sugar, extract 
of coffee combined with milk 
and sugar may be substituted 
by the Secretary of the Navy, 
if not more expensive. 



ARMY AND NAVY DIETS 711 

The law allows one of the above complete rations to be used on 
any or each day of the week, or they may each be used in turn as 
convenient, in case it becomes necessary to vary the order prescribed 
elsewhere. Estimated average cost per capita per diem, thirty cents. 

The following statement is from the New York Medical Record 
(1898) : 

" The naval full-diet table is as follows for one day in the week, 
the number after each article relating to ounces : Breakfast — coffee, 
1 ; bread, 4 ; butter, 1 ; milk, 6 ; sugar, 1 ; oatmeal, 1 ; beefsteak, 6. 
Dinner — rice soup, 8 ; bread, 4; roast beef or roast or boiled fowl, 8 ; 
potatoes, 8 ; other vegetables, 6 ; pickles, 1 ; bread pudding with 
sauce, 6 ; or custard frozen, 8 ; fresh fruit, 6. Supper — tea, J ; bread, 
6 ; butter, 1 ; milk, 2 ; sugar, 1 ; cold roast mutton or cold roast beef, 
4 ; stewxd dried fruit or baked fresh fruit or apple sauce, 4. The 
staples — coffee, bread, butter, milk, sugar, and fresh and dried fruit — 
are the same for each meal, but there is a daily variety in meats and 
other articles for breakfast, dinner, and supper. The proportions 
are about the same, however, especially in the matter of meats, as 
in the specimen diet table given above. In addition to its use for 
convalescents, the table is now observed for all naval-hospital em- 
ployees, and is gradually becoming the standard aboard ship and in 
the marine corps. Its adoption was the result of most patient and 
thorough investigation by Surgeon I. D. Gatewood, who consulted 
all the leading authorities on the subject." 

Table showing the Quantities of the Different Articles of the U. S. Navy 
Ration which are required for One Man for One Year 

Biscuit 319! pounds. 

Biscuit (with flour) 182 " 

Cornrneal 52 " 

Oatmeal 52 

Rye flour or hominy 52 " 

Wheat flour 52 

Salt pork 104 " 

Beans 6i gallons. 

Peas 3i " 

Salt beef 52 pounds. 

Rice 26 

Dried fruit 13 " 

Butter igi 

Tomatoes 19^ 

Canned meal 78 " 

Ham or bacon 39 " 

Sausage or salt fish 39 " 

Coffee 26 

Tea 4l " 

Cocoa 19^ 

Sugar gii " 

Pickles 26 " 

47 



712 



RATIONS, DIETARIES 



Molasses 3 1 gallons. 

Vinegar 3^ " 

Canned vegetables 39 pounds. 

The British Navy ration contains one pound of fresh meat, one 
pound and a half of bread, or one pound and a quarter of sea biscuit. 

In comparing navy with army rations it should be remembered 
that on shipboard a proper cooking range, utensils, and fuel are 
always obtainable, whereas wholly different conditions obtain with 
an army in the field. 

Table showing the Different Articles of the U. S. Navy Ration, for which 
Practical Equivalents or Substitutes are permitted, with the Quantity 
of each allowed for Issue 



Articles named in 
the Law. 



Bread. 



Flour. 



Preserved meat. 



Articles considered as included under names given in 
preceding column. 



Biscuit 

Soft bread 

Cornmeal 

Corn (hominy), 

Oatmeal 

Rye 



Dried fruit 

Tea 

Cocoa 

Fresh meat 
Vegetables. 



Wheat 

Roast beef. 

Canned mutton 

Chicago corned beef. 

Brawn 

Ham 

Bacon 

Sausage 

j Dried 

Fish -< Smoked 

( Pickled 

Dried apples. ] 

Peaches. 

Raisins. 

Currants. 

Prunes. 

Figs. 

Dates. 

May be substituted for each other 

Beef. 

Mutton. 

Veal. 

Pork. 

Poultry. J 

Fresh (such as can be procured). 

Canned (assorted kinds) 



■ Or any other kind of dried 
fruit 



Or any other kind of fresh meat 



Quantity allowed 
per ration. 



14 OZ. 
lib. 



As substitute for 
1 lb. bread. 



\ oz. 
2 oz. 



illb. 



Iilb. 
6 oz. 



DIET IN PRISONS 

In prisons, penitentiaries, or reformatories the diet should be 
adapted to keep the patients in good health through periods of 
years, while it is maintained at a minimum of expense to the com- 
munity. A brief review of such established diets is useful in furnish- 



DIET IN PRISONS 713 

ing an idea of quantity and quality of food required to fulfil the 
necessary conditions. 

Voit calculated that for a prisoner not engaged in hard labour 
the following diet is sufficient to maintain health : Carbohydrates, 
three hundred grammes ; albumin, eighty-five grammes ; fat, thirty 
grammes, or a proportion of about 10, 3.5, and I. 

In some penal institutions the inmates are placed upon a pro- 
gressive diet — that is, a diet which is regulated according to the 
duration of their sentence, the degree of labour exacted from them, 
and their conduct. Such a diet has been recommended by the 
British Commissioners of Prisons, graded for: (1) Periods of seven 
days or less. (2) Periods between seven days and one month. (3) 
Periods between one and four months. (4) Periods exceeding four 
months. 

A somewhat similar system is detailed below — that of the United 
States Army Prison at Fort Leavenworth. 

Diets of the United States Army Prison, Fort 
Leavenworth, Kansas 

general diet 

Breakfast. — Hash, on Tuesday, Wednesday, Thursday, Saturday 
and Sunday. Mutton or beef stew, on Monday and Friday. Coffee, 
one quart each morning. 

Dinner. — Pork, one day each week. Corned beef, one day each 
week. Roast beef and gravy, three days each week. Boiled beef 
and gravy, two days each week. Vegetable soup, daily except 
Sunday. 

One pint of coffee each Sunday. Pork may be substituted for 
corned beef or boiled beef one day each week during cold weather. 

To the above will be added pickled cucumbers, beets, or toma- 
toes on alternate days, and such other vegetables as may be avail- 
able from the prison farm. 

Supper. — Tea or coffee, one quart ; bread, as much as required. 
Stewed apples or prunes on alternate days. 

No. 1. The following diet, known as " Solitary," is given prison- 
ers confined in cells for punishment, while not performing any 
labour : 

Breakfast. — Bread, eight ounces, water ad libitum. 

Dinner. — Bread, eight ounces ; water ad libitum. 

This punishment is given only for short periods, varying up to 
twenty days. 

Total farinaceous foods, sixteen ounces. 

No. 2. The following diet, known as " Restricted," is given pris- 
oners confined in cells for punishment, while not performing any 
labour : 



7i4 



RATIONS, DIETARIES 



Breakfast. — Hash or stew, eight ounces. Bread, seven and a half 
ounces. 

Dinner. — Soup, eight ounces. Bread, seven and a half ounces. 
Salt ad libitum. 

Supper. — Bread, eight ounces. 

The eight ounces of bread for supper to be given after the 
twenty days of subsistence on the previous diet. 

Total proteid food, eight ounces ; total farinaceous food, twenty- 
three ounces. 

No. 3. The following diet is given to prisoners who have under- 
gone punishment : 

Breakfast. — Hash or stew, ten ounces. Bread, ten ounces. 
Coffee and sugar in the usual amounts. 

Dinner. — Soup, the usual amount. Beef, eight ounces, or pork, 
six ounces. Peas or beans, six ounces, or hominy in the usual 
amount, or potatoes, eight ounces. Xo other vegetables except 
such as are contained in the soup. 

Supper. — Bread, ten ounces. Tea and sugar in the usual 
amounts. 

To prisoners who have been on " Restricted Diet " for more 
than ten days and less than twenty days, or on " Solitary Diet " for 
ten days, the above diet (No. 3) is given for two days. 

For those who have been on " Restricted Diet " for twenty days 
or more, or on " Solitary Diet " for fifteen days, the above diet (No. 
3) is given for three days. 

The dietary of the New York State Reformatory will be found 
on pp. 716-718 in tabular form. 

The comparison of this Reformatory Diet with other standard 
rations is presented in the following table of actual nutrient values : 



Reformatory standard dietary daily ration * 

Actual upper first grade ration 

Actual lower first grade ration 

Actual second grade ration 

Playfair's standard for adults, moderate exercise. 
Voit's standard for labouring men at moderate work 

Voit's standard for prisoners in idleness 

Voit's standard for prisoners at work 



NUTRIENTS, IN 


GRAMMES. 


Protein. 


Fats. 


Carbo- 
hydrates. 

556 


119 


61 


167 


75 


8IO 


154 


69 


794 


154 


69 


776 


119 


5i 


53i 


T18 


56 


500 


85 


30 


300 


105 


40 


500 



Potential 

energy, 

in calories. 



3.334 
4,696 

4,524 

4.452 

3,140 
3.050 

1.857 
2,852 



* All food supplies are issued according to this standard dietary, except bread, 
which is unlimited. The average consumption of bread per man is somewhat in excess 
of one and one half ration per meal, thus accounting for the increase in value of the 
actual ration over that of the standard dietary, which conforms very nearly in food 
values to the standards of Voit and Playfair. 



DIET IN PRISONS 715 

At a Conference of the Prison Association of New York, the 
following bill of fare was recommended for general adoption in pris- 
ons. The quantity of food is not specified : 

Sunday 

Breakfast. — Pea soup, bread and butter. 
Dinner. — Baked beans, brown bread, pudding. 
Slipper. — Bread or crackers, cheese, milk. 

Monday 

Breakfast. — Oatmeal or boiled rice, with sugar and milk. 
Dinner. — Salt fish, vegetables, fruit. 
Supper. — Bread and butter, milk. 

Tuesday 

Breakfast. — Bean porridge, bread. 

Dinner. — Roast beef, two or more kinds of vegetables, bread. 

Supper. — Bread and milk, molasses. 

Wednesday 

Breakfast. — Pea soup, bread. 

Dinner. — Beef or mutton stew, with vegetables. (Rice may be 
used in place of potatoes.) 

Supper. — Cornmeal mush, molasses. 

Thursday 

Breakfast. — Bread and butter, milk. 
Dinner. — Baked beans, bread, fruit. 
Supper. — Bread and butter, cereal, coffee. 

Friday 

Breakfast. — Pea soup, bread. 

Dinner. — Fresh fish, vegetables. (Rice may be used in place of 
potatoes.) 

Supper. — Bread and milk, cheese. 

Saturday 

Breakfast. — Oatmeal mush, milk, bread. 
Dinner. — Corned beef, vegetables. 
Supper. — Bread and milk, molasses. 



716 



RATIONS, DIETARIES 



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RATIONS, DIETARIES 



From the New York State Reformatory Annual Report for i8gj 
Calculations based on Prof. Atwater's tables, with Reformatory standard diet added. 

COMPARISON OF DAILY DIETARIES 



Carbohydrates 



Fats 



Protein 



Potential energy 



Nutrients, Grammes 



Potential Energy, Calories 



200 400 600 800 1000 1200 1400 1600 

I 1 1 r- 




Subsistence diet (Playfair) 
Under-fed labourers, Lombardy, Italy 

Students, Japan 

Lawyers, Munich, Germany 

Well-paid mechanic, Munich, Germany 

Well-fed blacksmith, England 

German soldiers, peace footing 

German soldiers, war footing 

French-Canadian families, Canada 

Mechanics and factory operatives, Massachusetts 

Well-to-do family, Connecticut 

College students, Northern and Eastern States 

Machinists, Boston, Mass 

Hard-worked teamsters, etc., Boston, Mass 

U. S. Army ration 

U. S. Navy ration 

N. Y. State Reformatory standard 

Reformatory standard daily ration 

Actual upper first grade dietary 

Actual lower first grade dietary 

Actual second grade dietary 

Playfair's standard for adults, moderate exercise 
Voit's standard for labouring men at moderate work. 
Voit's standard for prisoners in idlene 
Voit's standard for prisoners at work 



THE MILK CURE 719 



THE MILK CURE 

An exclusive diet of milk as a cure for certain chronic diseases is 
advocated by some physicians, and in whose hands it has met with 
considerable success. Karell, of St. Petersburg, and Weir Mitchell 
are to be mentioned among those who have extensively used this 
form of treatment. The treatment as a " cure " does not apply to 
the temporary exclusive milk diet of typhoid fever and similar acute 
febrile conditions, but it is believed by the advocates of the milk 
diet that this form of food not only counteracts certain abnormal 
conditions and meets definite requirements of the body, but that the 
milk diet itself possesses a special curative value in some cases. 
Bauer says emphatically : " It is an indisputable fact that in certain 
diseases a methodical use of the milk cure gives results such as can 
be attained by no other treatment." 

It is recommended in obstinate cases of chronic intestinal dis- 
orders, especially neuralgia, intestinal dyspepsia, and colitis ; in 
chronic congestion, hypertrophy, and fatty degeneration of the liver ; 
in asthma, pulmonary catarrh, and emphysema ; in dropsies of renal, 
cardiac, and hepatic origin; in hysteria and hypochondriasis, in 
which the predominant symptoms are dyspepsia and malnutrition ; 
and in chronic catarrhal conditions of the whole alimentary canal. 

The milk cure is also recommended in cases of neurasthenia, 
obesity, rheumatism, gout, chronic valvular cardiac diseases, chronic 
Bright's disease, and endarteritis. 

Dosage and Method of giving the Milk. — The milk used is 
skimmed, and it is important to have it obtained as fresh from the 
country as possible. It is customary to begin with comparatively 
small doses — about four ounces, once in two hours throughout the 
day, with one or two doses at night. Karell gives the milk luke- 
warm. At the end of a few days the dosage may be increased to six 
or eight ounces, and the intervals made three-hourly, and finally 
four-hourly, when twelve tumblerfuls are given daily. Pecholier 
gave three litres per diem, in two-hourly doses. When the treat- 
ment is undertaken it must be carried out with absolute regularity 
and system, both as regards the quantity of milk consumed and the 
intervals at which it is given ; otherwise, if too large an amount is 
drunk at one time, or the intervals are too frequent, undigested milk 
remains in the stomach to mingle with the fresh doses, and abnormal 
fermentation and dyspeptic symptoms result. It is much better that 
the milk should be given alone whenever large quantities are to be 
taken for a long time. If diarrhoea exists, the milk may be boiled 
or taken hot at any time, if the patient so prefers it, but this is not 
necessary. If the passages from the bowels are normal in appearance 
— small and solid — the milk is being well digested and absorbed, 



J20 RATIONS, DIETARIES 

and the quantity may be increased. Usually the greatest difficulty 
with indigestion in this form of treatment occurs during the first 
week ; afterward, as a rule, the alimentary canal becomes accustomed 
to the diet and digestion proceeds actively and nutrition improves. 

Many patients — either from imagination or from past experience 
with milk drinking — insist that they are unable to take it in any 
form, but it is rare, indeed, to find any one who cannot digest milk if 
it is made palatable and properly prepared. For this purpose, sug- 
gestions will be found under the heading of the article on the Adap- 
tation of Milk for the Sick (p. 73), to which the reader is referred. 
Not a few learn to prefer the milk to more highly seasoned food. If 
the patient chooses — and it is wholly a matter of taste — the milk can 
be flavoured with very weak tea, weak coffee, or caramel, and a 
pinch of salt should be added in most cases to each tumblerful. Ex- 
ceptionally the flavour of a little spice of some sort may be preferred. 
Some patients do better if the milk is diluted by one third or one 
half with some alkaline table water, lime water, or Vichy, or it may 
be scalded with a little boiled water to which five grains of sodium 
bicarbonate and three or four grains of common salt are added. 
Milk from first-class thoroughbred cows, such as Alderneys, is often 
too rich, and it is undesirable to give any milk in this cure which 
contains much cream. Skimming the milk is therefore necessary in 
most instances, and in some cases, even after the milk is skimmed, 
it is better digested if considerably diluted. 

In carrying out this treatment much depends upon previously 
gaining the confidence of the patient and having him thoroughly 
understand the theory of the cure, so that his willing co-operation 
may be obtained in a method which is monotonous and wearisome at 
best. By a little tact and persuasion with care in framing the origi- 
nal rules and supervision over their execution the cure may often 
be conducted with great benefit in seemingly difficult cases. The 
one object of the treatment is to enable the digestive organs to rest 
and recuperate when they are in an exhausted or irritable condition 
by giving only small quantities of the simplest form of food at first. 
Later, as digestion improves, larger amounts will be tolerated and 
the strength and nutrition of the patient will be promoted by in- 
creasing the dosage of milk to whatever maximum can be reached 
without taxing the stomach. 

Symptoms accompanying 1 the Treatment. — The frequent occur- 
rence of constipation is a not unfavourable indication that the milk 
is lacing well digested and very completely absorbed, leaving but 
small residue. Diarrhoea or obstinate vomiting, on the other hand, 
indicate indigestion and malnutrition, and the difficulty should be 
corrected by temporarily reducing the quantity of milk and pro- 
longing the intervals between the doses to four or even six hours. 
The constipation is met by the use of a pill of two grains of inspis- 



THE WHEY CURE 721 

sated oxgall, or by the compound licorice powder (pulvis glycyr- 
rhizae compositus), or a dose of rhubarb, or half an ounce of castor 
oil, or thirty to sixty minims of fluid extract of cascara. The addi- 
tion of coffee to the milk drunk in the earlier hours of the day some- 
times renders it more laxative, and, if necessary, prunes or stewed 
or baked apples may be taken once daily, in the middle of the 
afternoon. 

In addition to the milk, patients should be allowed a reasonable 
quantity of water or of aerated waters. It is well that some water 
should be given even though thirst be not complained of. After a 
fortnight or three weeks some patients complain very much of the 
absence of solid food, and in such cases — if the digestion is favour- 
able — stale bread, crackers, dry toast, or a little salted Dutch herring 
may be allowed, or a milk soup thickened with barley or groats. 
Some patients do well to take one of the prepared starchy foods, 
such as are in familiar use for infant feeding. As a usual result of 
the treatment, patients lose weight somewhat during the first ten 
days or two weeks, but after the quantity of milk begins to be in- 
creased they may gain considerable flesh and strength, excepting in 
the case of very obese persons, who may continue to lose fat after 
the maximum dosage of milk has been attained. Drowsiness is also 
a common symptom in the first few days. The urine is increased, 
and is pale in colour and of low specific gravity. The tongue is 
covered with a thick white or yellowish coating, and there is usually 
a disagreeable, mawkish taste in the mouth. The latter condition 
may be relieved very largely by proper care (compare Treatment of 
Typhoid Fever, p. 426). The increased quantity of urine is possibly 
clue to the large amount of lactose, which is somewhat diuretic in 
action ; but when given alone I have not found it to possess excep- 
tional power in this direction. According to Weir Mitchell, the 
uric acid is greatly reduced in the urine and the colour is of a some- 
what greenish hue, and indol and skatol also disappear. Weir 
Mitchell calls attention to the extensive changes in assimilation in 
the body which these various alterations in excretions indicate. 

After about six weeks of this milk diet the substitution of solid 
food is to be gradually made, reducing the number of milk meals by 
at first one a day for a day or two, then by two, and so on until all 
food is taken solid, and Karell suggests that lean, raw scraped beef 
with stale bread is the best to begin with. The diet should be so 
graded as to consist largely of milk for several months. 

THE WHEY CURE 

The whey cure has been extensively practised in the mountain- 
ous regions of Germany and Switzerland and at various springs or 
baths, especially those of the alkaline waters, which latter are fre- 



722 RATIONS, DIETARIES 

quently mingled with the whey and drunk either warm or cold. The 
treatment is rigorous, and consists in confining the patient's diet 
largely to the use of about twenty ounces per diem of fresh milk 
whey. The principles of the treatment are essentially similar to 
those of the milk cure, but in whey the casein of the milk has been 
artificially removed to make cheese by the addition of rennet, the 
milk-curdling ferment. 

Whey is made from the milk of several animals, such as the 
sheep, goat, mare, and ass, as well as the cow. It consists of milk 
sugar, albumin, substances resembling peptone, and a smaller quan- 
tity of fat with most of the lactic acid. It is whitish, translucent, 
and opalescent. 

When milk has been standing for some time in the air it becomes 
contaminated with bacteria, which cause spontaneous coagulation, 
and whey is squeezed out of the contracting clot ; but this is sour 
and not so good as that made by rennet. The percentage composi- 
tion of whey is as follows : 

Water 93-31 

Lactose 4-65 

Fat 0.24 

Proteid o. 82 

Lactic acid o . 33 

Salt 0.65 

The whey cure is used for the treatment of Bright's disease and 
chronic catarrhal conditions of the alimentary canal. It is partic- 
ularly recommended for chronic dyspepsia and chronic irritable 
cough accompanying catarrh of the respiratory mucous membranes. 

It is said to improve the secretion in chronic bronchitis, and it in- 
creases the strength of the pulse, which is attributed to its potassium 
salts (May). If more than twenty ounces are ingested daily there 
is an increased peristaltic movement, with watery evacuations, colic, 
and dyspepsia. 

Whey, like skimmed milk, is diuretic and sudorific. It therefore 
constitutes a useful beverage in fevers. The class of patients, many 
of them phthisical, for whom the cure is recommended at Ems, 
Ischl, Reichenhall, etc., are not fit subjects for a reducing diet, as 
they have little or no spare strength ; they require rather abundant 
nourishment, owing to the catarrhal processes which affect the re- 
spiratory and alimentary passages. However, in such cases diges- 
tion and absorption are often greatly impaired, and this condition is 
found to be benefited by the use for a short period of the alkaline 
waters and whey. It is not safe to limit the diet exclusively to these 
fluids, and some nitrogenous food must be given, together with 
fresh fruit and green vegetables. In Switzerland and Germany the 
whey cure is often combined with the grape cure. 



FRUIT CURES 723 



VARIOUS "CURES" 

There are other diet systems or " cures," which deserve passing 
mention rather as matter of general interest and as illustrations of 
the effects of strong mental impressions or " mind cure " combined 
with moderation in previous habits of overeating or gluttony, than 
because any specific importance is to be attached to the value of 
one such " cure " more than another. 

Many diet " cures " have been devised purely for notoriety, to 
advertise an otherwise unsuccessful practitioner or a charlatan, and 
others again are exploited by well-meaning fanatics who have ac- 
quired a firm belief in some dietetic system which has first helped 
themselves, and which they feel that they owe to the world to pro- 
mulgate for the guidance of others. But they are not always even 
pretended followers of iEsculapius. Mr. Banting (p. 626), whose 
name has given rise to a verb meaning to reduce corpulency, was a 
layman, and so was Mr. Graham, whose name is a household ad- 
jective applied to the flour which he introduced, and many famous 
men, like Shelley and Goldsmith, have sung the praises of vege- 
tarianism. 

Not infrequently an element of religious fervour is added to the 
belief in the efficacy of some new system, and long pilgrimages are 
made to seek its chief apostle. Such, for example, is the 

Kneipp System. — Monseigneur Kneipp was a Bavarian priest 
whose patients lived chiefly upon a diet of milk, coarse bread of bran 
and flour, soup, and cooked fruits, with a minimum of meat, eggs, 
and vegetables. Water was principally drunk, with a little wine or 
beer, but no spirits or coffee. This is undoubtedly a common-sense 
regimen for many persons who have long abused their gastronomic 
powers by eating too much and too rich food, but the ascetic ele- 
ments were added of wearing very light, loose apparel and walking 
about barefooted in the grass before the morning dew vanished. 

FRUIT CURES 

The " fruit cure " has appeared in many forms. At one time it 
is confined to oranges, English walnuts, and cold water, and, strange 
to say, some dyspeptics are able to digest it for a short time; or it 
consists of sweet fruits and meat alone — dates, figs, prunes, bananas, 
and apples — upon the theory that fruits were the first food of prime- 
val man, and ergo they are the natural food of all men — an extreme 
of atavism, surely ! There is also a " lemon cure." 

Another fruit cure extends through six weeks. It begins grad- 
ually by eating an apple or orange upon rising and again upon retir- 
ing. In three or four days the breakfast consists of several baked 
apples, a small quantity of bread and butter, and a little coffee. 



724 RATIONS, DIETARIES 

During the forenoon several ripe apples or oranges may be eaten. 
At dinner fresh animal food is furnished with a potato and roasted 
apples or apple sauce. Green vegetables are allowed, but no bread 
or pastry of any kind. Pickles may be eaten. During the after- 
noon, more fruit, oranges, apples, grapes. Supper, like breakfast, 
with a little sago in milk, with currants, raisins, or apples. This 
diet is adapted to obstinate chronic constipation, some cases of 
obesity, and lithsemia. 

THE GRAPE CURE 

The grape cure has been advocated for many years as beneficial 
in certain forms of disease, but, like the majority of vaunted dietetic 
" cures," it is almost certain that the chief benefit experienced is 
from the change of scene and the favourable climatic and hygienic 
surroundings of the patient, and possibly the influence of a stimu- 
lated imagination. The " cure " is in vogue during the grape-bear- 
ing season of the vineyards in various parts of southern Europe, 
especially at Meran and Montreux. Grapes, being very largely 
composed of water, do not possess a very high degree of nutritive 
power, and it is impossible to maintain life upon their exclusive use ; 
but the grape sugar which they contain, as well as a large amount of 
potassium and other salts, may have some slight alterative effect 
and benefit nutrition. Grapes are also laxative. Almost every one 
is fond of the fruit, and the cure is therefore an agreeable one to 
take, especially as the diet is not too exclusive, for the eating of 
large quantities of grapes is made an adjunct to the employment of 
highly nutritious food. 

Vineyard labourers who eat little else but grapes quickly lose 
weight, and other food must be taken with the grapes if the strength 
is to be maintained, for a pound of grapes contains a little less than 
three grammes of proteid. 

It is recommended by Lebert that the grapes should be eaten 
systematically and in quantities commencing with half a pound, and 
seldom exceeding four pounds per diem, although six or eight 
pounds are sometimes eaten, a quantity which may excite diarrhoea. 
Owing to the mildly laxative effect of the fruit, this cure is bene- 
ficial in cases of chronic constipation, and especially in engorgement 
and hyperemia of the liver accompanied by extensive venous con- 
gestion, hemorrhoids, and the formation of various forms of calculi. 
In gastric catarrh patients are sometimes allowed to eat six pounds 
of grapes a day. The laxative effect is always greater if the fruit is 
taken in the intervals between meals, and especially if taken fasting 
on rising in the morning. At first only half a pound of grapes is to 
be taken two or three times a day, from half an hour to an hour 
before meals, the quantity being gradually increased to a pound or 



THE GRAPE CURE 725 

more at each dose. Some patients digest the grapes better, however, 
if they are eaten in the form of dessert than if taken into an empty 
stomach. The laxative effect gradually increases, and is usually 
more pronounced after several days. The uric acid and acidity of 
the urine is lessened. 

When patients become tired of the monotony of this single fruit 
they may be allowed to substitute pears or figs. It is stated that the 
gums may become somewhat swollen and tender from the acid con- 
tained in so much fruit, and to obviate this difficulty the mouth may 
be cleansed thoroughly after eating with listerine or a solution of 
sodium bicarbonate, or the mastication of a small quantity of bread 
will serve to cleanse the teeth. 

Abundant other food is allowed with the grapes, but it is impor- 
tant that it should be of an easily digestible character, and certain 
articles must therefore be forbidden, such as fats, rich sauces, gra- 
vies, pickles, condiments, the heavier vegetables, such as potatoes 
and the legumes, cheese, pastry, cakes, sweets, and beer. 

The usual duration of the cure is from a month to six weeks. 
The average chemical percentage composition of grapes is given by 
Konig as : 

Water 78.17 

Sugar « 14 . 36 

Free acid. o. 79 

Nitrogenous material o. 59 

Extractives 1 . 96 

Stones and woody fiber 3 . 60 

Ash 0.53 

The latter is chiefly composed of potash salts, some lime and 
magnesia. 

Patients who have undertaken the grape cure without proper 
supervision easily disorder their digestion and cause gastric catarrh 
and even jaundice. Knauthe says that the eating of several pounds 
of grapes daily may at first cause symptoms of flatulent dyspepsia, 
more or less vertigo, and increased frequency of the pulse, palpita- 
tion, diuresis, and malaise. The stools become more frequent and 
semisolid. 

The grape cure is reputed to be useful in chronic bronchitis, the 
first stage of phthisis, emphysema, in obesity when combined with a 
restricted diet, in gastro-intestinal catarrh, anaemia, vesical catarrh, 
gout, hepatic engorgement, malarial cachexia, and chronic cutane- 
ous affections. 

In phthisis the grapes should not be given in quantities sufficient 
to occasion diarrhoea. 



726 RATIONS, DIETARIES 



MEAT AND HOT-WATER CURE 

The meat and hot-water cure, often called in this country by the 
name of Salisbury, one of its chief advocates, is given to many 
classes of patients — consumptives, rheumatic subjects, and others. 
Lean raw beef is ground to a pulp in a machine which is made for 
the purpose and sold in hardware shops. It is freed from all fibre, 
seasoned with salt and pepper, rolled into little balls, and cooked 
just enough to turn the outside from a red to a drab colour. From 
two to four ounces are eaten at a meal at first ; later as much as 
seven ounces may be taken. In addition, from two to four raw eggs 
are given with dry toast. Xo fluid is allowed with meals, but from 
a half pint to a pint of hot water is given before each meal, and 
again at bedtime. 

This diet reduces corpulency rapidly, and is beneficial in cases of 
chronic gastric catarrh and dilatation, but it is too rigid for many 
patients. It is somewhat similar to, but much more strict than, the 
diets of Carlsbad and Wiesbaden, which consist chiefly of lean meat, 
eggs, and milk with a minimum of bread, and sometimes fruit. 



THE DRY CURE 

The " dry cure " is the name given to the treatment which con- 
sists in withholding fluid from the diet in increasing degree until the 
patient takes just as little as is necessary to sustain life. If carried 
to this extreme, however, thirst becomes intolerable, and patients 
usually rebel against the rigour of such treatment. 

Practically it is found that the minimum of water aside from that 
contained in food which patients can tolerate is about fifteen ounces 
per diem, which should be taken between meals. For the relief of 
thirst in these cases various measures are employed, such as are 
described on p. 43. 

In Germany the dry diet has been tried extensively in some cases, 
especially those of gastric dilatation and cases of chronic effusion 
into the joints and in the peritoneal cavity. There are many forms 
of disease in which it is well to temporarily restrict very much the 
quantity of fluid consumed, but it is hardly ever justifiable to do so 
to the degree recommended by enthusiastic advocates of the "dry 
cure," among whose patients fatal cases of scurvy have occurred as 
well as cases of fever with a temperature sometimes amounting to 
104 F. The conditions in which the quantity of fluid drunk should 
be especially restricted are gastric dilatation, chronic serous effu- 
sions, flatulent dyspepsia due to indulgence in sweets, coffee, tea, 
etc., some few cases of obesity, and aneurism of the aorta (compare 
Tufnell's treatment, p. 482). 



diet for athletic training 727 

Schroth's Method 

The dry cure of the yeoman John Schroth has achieved some 
notoriety in Europe, where several " institutes " have been estab- 
lished for its practice. It is a rigorous method which many patients 
find difficult to endure. The diet is gradually reduced in quantity 
and variety at first for a few days, and then the actual " cure " is 
begun, which consists in giving no fluid at all, excepting a small 
glass of hot wine twice a day for as many days as the patient will 
endure it. Boiled vegetables are allowed for dinner, and otherwise 
nothing is given but dry bread. Thirst becomes so extreme that in 
three or four days the patient is allowed to drink hot wine freely to 
quench it, after which the quantity of fluid is again cut down to two 
small glasses a day until the patient is again obliged to receive more. 

This treatment has in some cases been carried to the verge of 
starvation with extreme prostration and fever, and it has little or 
nothing to recommend it. Even fatal scurvy has followed its use at 
Kiel. It is based upon the theory that the blood becomes more 
dense, which favours osmosis between the serum and the surround- 
ing lymph and tissues. As an adjunct to the treatment hot moist 
packing is employed. 

Jurgensen modified the treatment by giving from one third to 
two thirds of a pound of lean beef with bread as desired, and light red 
wine. It has been found by this writer and by Bartels that proteid 
metabolism is undoubtedly increased by the dry diet, for the urine 
contains nitrogenous waste in as large a proportion as when the 
patient is upon a full diet — in some cases there is even more than 
the normal. 

Upon slowly resuming the accustomed diet a considerable gain 
in weight compensates for previous loss, which is attributed in part 
to restoration of water to the tissues. Bartels noted an increase in 
urea which was greatest immediately after the treatment. The con- 
siderable rise of temperature (104 F.) which accompanies this treat- 
ment is explained by the facts that but little water is evaporated 
from the lungs and skin, and that the body heat is retained by the 
hot packs. 

The treatment has been applied with some success in obstinate 
cases of syphilis, gastric dilatation, chronic rheumatism, and chronic 
peritonitis. 

DIET FOR ATHLETIC TRAINING 

The object of dietetic " training " in athletics is to fit men either 
for feats of great muscular endurance and strength or for exhibitions 
of dexterity requiring accurate and quick muscular movements and 
nerve control. The method of training naturally differs consider- 
ably according to the object to be attained. Professional athletes, 
48 



728 RATIONS, DIETARIES 

who are more or less constantly employed in exhibitions of 'strength 
or muscular skill, are obliged to adopt very regular habits of life in 
regard to sleep, bathing, and diet, and abstinence from the excessive 
use of tobacco and strong drink. In addition, when they enter spe- 
cial contests requiring continued feats of endurance, as in prolonged 
bicycle races or walking matches, for example, they have to undergo 
a period of special training for several weeks before the contest. 
Young men who devote themselves to athletic sports in college 
usually do so for a comparatively limited period, and are not sub- 
jected to such special strain or feats of endurance excepting, per- 
haps, in boat races, which are of short duration. As a general rule, 
from six to ten weeks is ample time to cover their course of special 
dietetic training, although they usually exercise ordinary care in 
such matters for a longer period before their contests. 

The physiological objects to be attained by any system of dietetic 
training are to reduce the fat and water contained in the tissues of 
the body, to increase the functional activity of the muscles, to train 
both muscles and nerves, improve the breathing power or " wind," 
the heart action and the condition of the skin. This is accomplished 
by carefully regulated diet, systematic exercises directed to the in- 
crease of oxidation processes, and the more perfect elimination of 
waste matter from the system. Dietetic training prevents the with- 
drawal of protein from other tissues than the muscles and supplies 
an excess of protein to make good any loss of this material. The 
protein is needed to build up muscle protoplasm and repair it. 

Rigorous dietetic training should be conducted with great care 
and supervised only by those who are experienced in such matters,, 
for any system carried to excess may cause too great a reduction in 
weight, and its object will be defeated by breaking down the indi- 
vidual at the moment of critical contest or laying the foundation for 
future organic weakness and disease. The heart may become hyper- 
trophied and subsequently fail in accommodation. 

It may be observed, however, that much of the ill effect of ath- 
letic training may be due not so much to any particular form of 
exertion or to being trained " too fine " in diet, but to the fact that 
the system brings to light constitutional weaknesses which were 
unsuspected until revealed by unwonted effort — in short, the system 
involves survival of the fittest. 

The transition from ordinary diet to that of any training system 
should be made gradually, and the return to the usual diet after a 
period of rigid training should be similarly slow. For the first two 
or three weeks of training athletes usually lose in weight an amount 
proportionate to their previous condition of robustness, but after 
several weeks an equilibrium should be reached in which, upon an 
established diet, the body weight remains practically the same while 
the muscular strength and vigour and power of endurance increase ; 



DIET FOR ATHLETIC TRAINING 729 

the complexion improves in appearance, the skin becomes clear, the 
muscles become firmer, and all superfluous fat disappears. 

While individual dietaries differ in training for the various forms 
of contest, most of them include lean meat, chiefly rare or " under- 
done," either roasted or broiled ; the bread should be dry or toasted; 
a moderate quantity of potatoes and green fresh vegetables and fruits 
are usually allowed. The class of foods to be especially forbidden 
are sweets, pastry, entrees, rich puddings, sour pickles, and condi- 
ments. For beverages, weak tea or coffee may be allowed, although 
sometimes, where the object of training is the attainment of special 
skill in feats of delicate balancing, all forms of nerve stimulants, 
including tea, coffee, and tobacco should be prohibited. Chocolate 
and cocoa, if not too sweet, may be sometimes allowed, and in some 
training systems the use of light beer and light wine in moderation 
is included, but strong alcoholic spirits are absolutely forbidden. As 
a rule, three meals a day at intervals of about six hours are recom- 
mended. 

The ancient Greek and Roman athletes used to train very largely 
upon a dry diet, which at first consisted of fresh cheese, dried figs, 
and preparations of wheat. Later they ate such meats as pork, beef, 
and goat flesh. 

Parkes gives the amount of fluid which may be allowed as about 
five pints in winter and six in summer, a little over one fourth of 
which is contained in the food. Drink should not be taken either 
shortly before exercise or during meals. If the mouth be well rinsed 
before drinking, less fluid will be required, and what is taken should 
be drunk slowly. 

The use of tobacco, particularly in the form of cigarette smoking, 
must be forbidden, and as alcohol in excess lessens the power of 
sustained muscular exertion, not over two ounces per diem can be 
allowed. 

The following dietaries of training have been kindly furnished me 
by Dr. Hartwell, who has had much personal experience in such 
matters : 

DIETARY OF THE BOAT CREW AT YALE UNIVERSITY 

From March 1st till June 10th (ten weeks and a half), the hours 
of work are from 4 to 7 p. m., with exercise for an extra half hour or 
more at such odd times as recitations may permit. During this pe- 
riod the following regulations of the training table are observed : 

Breakfast, 7.30 a. m. 

Fruit. — Oranges, tamarinds, figs, and dates. 

Cereals. — Oatmeal or one of the many preparations of wheat ; a 
rich milk (not cream) and sugar are allowed with this. Toast. No 
hot breads are allowed. 



730 RATIONS, DIETARIES 

Meats. — Beefsteak (usually rare), chops, stews, hash. Once or 
twice a week some salt meat, as bacon or ham, is allowed, and with 
it usually liver. 

Potatoes. — Stewed, browned, and baked. 

Eggs. — Served in all styles, except fried (unless with the ham). 
Eggs appear in some form about four mornings a week. 

The meats are varied, steaks or chops alternating with one of the 
others. 

Fluids. — Water, milk, tea on special occasions for some indi- 
vidual man. The water is boiled and poured while hot on the oat- 
meal. On cooling it has about the consistence of rich milk and a 
strong flavour of the oatmeal. 

Dinner 

Soups. — All varieties, including oyster stews and clam broths. 

Meats. — Roast beef, mutton, turkey, chicken. Gravies are but 
little used. Two kinds of meat are always served. 

Fish, broiled or boiled, is served twice a week. 

Vegetables. — Potatoes (mashed or boiled). Tomatoes, stewed or 
sometimes raw. Beans, peas, corn (occasionally). Two vegetables 
besides potatoes are usually served. 

Bread. — Toast. 

Dessert. — Puddings — rice, bread, tapioca ; but little butter is al- 
lowed in their preparation. 

Fruit. — Same as breakfast, with berries and cantaloupe in season. 
Baked apples. 

Fluid. — Same as breakfast. 

Supper (one hour after rowing — i. e., from y to 8.15 p. m.) 

Cereals. — Same as breakfast. 

Meats. — Chops, stews, cold meats from dinner. Rarely, beef- 
steak. 

Potatoes. — Stewed or baked. 

Eggs. — All styles, about three times a week, usually not on same 
day as for breakfast. 

Fluids. — Same as breakfast. Bass's ale for men who are getting 
" fine " and for whole crew after especially hard day's work. 

Ale and milk are never taken at same meal. 

For three weeks following June 10th the crew is at New London 
in final preparation for their race. The programme is then some- 
what changed. 

Breakfast is served at the same hour and consists of the same 
variety of food as before. 

The morning work is from 9.30 or 10 to 11.30 or 12. 

Dinner, with same menu as before, is served at 12.30 or 1 p. m. 



DIET FOR ATHLETIC TRAINING 731 

Luncheon. — The afternoon till 4.30 is spent in loafing — often in 
the water in the steam launch. At that hour a lunch of cold meat, 
stewed or baked potatoes, milk, and toast is served. The afternoon 
work — which is the hard work of the day — begins from forty-five to 
sixty minutes after the lunch and continues for about two hours, 
more or less, depending on its severity. Forty-five minutes after 
this work cold oatmeal or other cereal, with toast and milk, is 
served. 

Many of the men are allowed ale every night during the final 
three weeks, either with the late supper or an hour later — 9.30, on 
retiring. 

Quantity of Food and Fluid. — There is no limit set to the quantity 
of food. The fluids, however, are limited to three glasses at a meal, 
with but little drink between meals. Of late years this is becoming 
changed, and in hot weather, when the men are perspiring freely, 
more fluid is allowed. To counteract the constipating effect which 
training has upon some men, stewed prunes are served for either 
breakfast or supper. 

The training table of the present day, as given above, is far more 
liberal than it was five or ten years earlier, and it is aimed to regulate 
it on a rational basis. What few statistics are at command seem to 
show that the new is an improvement on the old system, and cases 
of overtraining are less frequent and less serious now than formerly. 

It is the opinion of J. W. White that " an ordinary farmhouse 
table with its midday dinner and early tea will rarely (with the ex- 
ception of coffee, hot cakes, pastry, and fried meats) offer anything 
which should be excluded from a rational training diet as it is at 
present understood." 

DIET OF HARVARD UNIVERSITY CREW 

The Harvard University Boat Crew diet while in active training 
in 1898 was studied for six days by W. O. Atwater and A. P. Bry- 
ant. The average weight per man was 162 pounds. A daily loss 
of from 2 to 3f pounds per man was produced by rowing and re- 
stored before the next day. As much as 4J pounds is sometimes 
lost by a man during a four-mile race, and i-| pound may be lost 
through worry and excitement immediately preceding the race. 

" The diet was simple. Roast and broiled beef and lamb, fric- 
asseed chicken, roast turkey, and broiled fish, made up the meats. 
Eggs were used plentifully either raw, poached, or boiled in the shell. 
Large amounts of milk and cream were also consumed. Oatmeal, 
hominy, and shredded wheat were eaten largely, and corn cakes 
were occasionally served. Bread was almost always taken in the 
form of dry toast. Potatoes were served twice a day. These were 
sometimes baked, sometimes boiled and mashed with a little milk 



732 RATIONS, DIETARIES 

and butter added, and at other times ' creamed.' Boiled rice, pre- 
pared with a little cream and sugar, was served instead of potatoes at 
some meals. Beets, parsnips, green peas, and tomatoes were used 
to furnish a variety of vegetables. Macaroni was occasionally 
served. For dessert, apple tapioca pudding, custard pudding, or 
other pudding containing a large proportion of milk and eggs was 
used. The members of the crew were allowed beer once a day. 
Xo pastry was allowed, and the puddings were, as above stated, com- 
posed largely of eggs and milk. A small amount of coffee jelly was 
served, and at one meal during the study ice cream. No fresh fruit 
was served, with the exception of oranges for breakfast. Stewed 
prunes, rhubarb, or apples were also eaten, prunes most abundantly. 
Xo beverages were allowed other than water, milk, and beer. 
Breakfast was served at 8, lunch at i, and dinner at 6 o'clock." 

These experimenters found that the average nutrients consumed 
per man per diem amounted to 145 grammes protein, 170 grammes 
fat. and 375 grammes carbohydrates, aggregating 3,705 calories. 
Just before racing each man received one ounce of beef extract 
with eight ounces of dry toast. 

A subsequent study of the Harvard University Boat Crew was 
made in 1899 by E. A. Darling, who reports as follows: 

" Diet. — The diet allowed was a very generous one, consisting 
of a hearty breakfast at 7.30, lunch at 1, and dinner after the even- 
ing row. For breakfast the fare consisted of fruit, oatmeal, or shred- 
ded wheat, eggs, some form of meat, bread and butter, potato, and 
milk. At noon there was cold meat, potato, bread and butter, 
marmalade, preserved fruit, and milk. Dinner comprised soup, 
occasionally fish, roast beef or some other hot meat, several vege- 
tables, bread and butter, and a simple dessert. No tea or coffee 
was allowed, but ale or claret was permitted at dinner, also water 
in small amounts, as desired. During the last week before the race 
each man received a dish of calf's-foot jelly with sherry wine after 
the morning row, and a light lunch of oatmeal, milk, and bread was 
served at 4 o'clock in the afternoon." 

Another study of the Harvard Freshman Crew during training 
was made in 1898 by Atwater and Bryant : 

" The men arose at about 7 o'clock. Before this time no noise 
was allowed in the kitchen or elsewhere. After a short run, break- 
fast was served at 7.30 o'clock and was quite a hearty meal, consist- 
ing principally of oranges, a breakfast cereal, hot meat or fish, and 
potatoes. During the morning there was usually a practice row 
on the river, followed by a light lunch at about 11.30 to 12 o'clock. 
The principal meal of the day was taken early in the afternoon. In 
the late afternoon the crew had another season of hard work on the 
river, after which another hearty meal was served. Leisure time 
was spent in study or recreation." 



DIET FOR ATHLETIC TRAINING 



733 



Sugar in large quantity may be added with advantage to the diet 
of athletes and soldiers on the march. It may be given with other 
food, such as cereals, tea and coffee, etc., as is customary with the 
Cornell University Crew ; or it may be given separately either as 
plain confectionery or in the form of cakes of chocolate. In a re- 
cent study of the training diet of boat clubs in Holland as much as 
one third of a pound of sugar per man per diem was found to be 
consumed with very marked benefit. 

Summary of Results of Dietary Studies of University Boat Crews and 
other Dietary Studies, by W. O. Atwater and A. P. Bryant, igoo 

(Nutrients in food actually eaten per man per day) 



DIETARY STUDIES OF UNIVERSITY BOAT CREWS 

Harvard University crew at Cambridge 

Harvard Freshman crew at Cambridge 

Yale University crew at New Haven 

Harvard University crew at Gales Ferry 

Harvard Freshman crew at Gales Ferry 

Yale University crew at Gales Ferry 

Captain of Harvard Freshman crew 



Average. 



SUMMARISED RESULTS OF OTHER DIETARY STUDIES 

Football team, college students, Connecticut. . . 

Football team, college students, California 

Professional athlete, Sandow 

Prize fighter, England 

Average of 15 college clubs 

Average of 14 mechanics' families 

Average of 10 farmers' families 

Average of 24 mechanics' and farmers' families. 
Average of 14 professional men's families 



Man 

Man 
Man 
Man 
Man 
Man 
Man 
Man 



DIETARY STANDARDS 

with moderate muscular work, Voit 
with moderate muscular work, Playfair. 
with moderate muscular work, Atwater. 

with hard muscular work, Yoit 

with hard muscular work, Playfair 

with hard muscular work, Atwater 

with severe muscular work, Playfair. . . . 
with severe muscular work, Atwater. . . . 



Protein. 


Fats. 


Grms. 


Grms. 


162 


175 


153 


223 


145 


I70 


160 


170 


135 


152 


171 


I 7 I 


155 


l8l 


155 


177 


1S1 


292 


270 


416 


244 


151 


27S 


73 


107 


I4S 


103 


T50 


97 


I30 


100 


141 


104 


125 


11S 


56 


119 


51 


125 




U5 


IOO 


156 


71 


150 




185 


71 


175 





Carbo- 
hydrates. 



Fuel 

value. 



Grms. , Calories. 

449 
463 

375 
448 
416 

434 

487 



440 

557 
710 
502 
S3 
459 
402 

467 
429 

423 



5 CO 

53i 

450 
568 

568 



4,130 
4,620 
3,705 
4,075 
3,°75 
4,070 

4,315 

4,cS5 



5,740 
7,885 
4,460 
2,205 
3,690 
3,465 
3,515 
3,48o 

3o25 

3,055 
3,140 
3,5oo 
3,370 
3,630 
4,5oo 
3,750 
5.700 



DIET OF YALE FOOTBALL TEAM 

" The diet of the football team is practically the same as for the 
crew except for lunch, which is eaten at 1 p. m., the practice taking- 
place from 2.30 to 3.45 or 4 p. m. This one-o'clock meal consists of 
cold meat, one chop or eggs, hot broth or bouillon, and toast. Milk 
and oatmeal-water are drunk. Apple sauce is sometimes allowed " 
(Hartwell). 



734 RATIONS, DIETARIES 



DIET OF PUGILISTS, JOCKEYS, AND BICYCLE RACERS 

Chambers gives the following example of a diet used by 
pugilists : 

7 a. m. Light breakfast : oatmeal with little or no milk and 
sugar ; one to three eggs, poached or raw ; a cup of tea with little or 
no milk or sugar; a slice or two of toast. The eggs may be varied 
by a rare or well-broiled chop. 

12 noon. Dinner (following a half hour of rest) : roast beef or 
mutton and vegetables; cup custard and plum pudding. A heavy 
dinner may be eaten, unless it is desired to reduce the weight. Old, 
mixed, or Bass's ale is allowed, but only a little water should be 
drunk, for it favours obesity. If thirst is annoying, a pebble may be 
carried in the mouth to increase the flow of saliva. 

An hour or two of rest should be taken after dining. 

6 p. m. Light supper : toast, a mutton chop or an egg, a vege- 
table, and a cup of tea. 

Percy studied the diet of a prize fighter twenty-two years of age, 
5 feet 6 inches in height and weighing 119. pounds. " He break- 
fasted at 9 a. m., and ate one pound of mutton, weighed before cook- 
ing. He dined at 1 p. m., and ate the same quantity of mutton, with 
the addition of about two ounces of bread. And again at supper, at 
8 p. m., he had the same quantity of mutton. At each meal he drank 
half a pint of ale, but no other liquid at any other time of the day. 
Nor did he eat any other vegetable matter whatever besides the small 
quantity of bread mentioned. He walked seventeen miles per day." 

Such a diet would not be indorsed by most trainers, nor would 
it fit a man for sustained effort. 

A noted New York prize fighter says that in training he is accus- 
tomed: to eat almost any plain substantial food that he likes, relying 
largely upon beef, mutton, bread, and potatoes, but avoiding pastry 
and sweets. He drinks fluid freely until within a week of the con- 
test, when he reduces the water ingested to a minimum. 

Bicycle racers entering six days' contests undergo the severest 
kind of muscular strain and require a diet rich in protein and energy. 
They work from eighteen and a half to twenty-one hours out of the 
twenty-four, and have a minimum of sleep. They take most of 
their food in fluid or semisolid form, in part to save time and in part 
because it is easily digestible. Water is not drunk during the race. 
A dietetic study of bicycle racers was made in 1898 in New York 
by W. O. Atwater and H. C. Sherman. The most remarkable con- 
testants were C. W. Miller, who rode 2007.4 miles in six days, and 
F. Albert, who rode 1822.6 miles. Miller lost four pounds the first 
day, but subsequently maintained his average weight. His average 
daily food consumption in grammes was: Protein, 169; carbohy- 



DIET AND OCCUPATION 735 

drates, 585 ; fat, 181 ; having a total fuel value of 4,770 calories. His 
food was of very simple character, and pastry and pork, as well as 
alcohol and tobacco, were excluded during a month of training. 

Albert, on the other hand, limited his diet chiefly by the exclu- 
sion of veal and fat meats. He smoked tobacco in moderation but 
did not use alcohol. He lost three pounds and a half in weight on 
the first two days of the contest, but subsequently regained them. 
His average daily food consumption in grammes was: Protein, 179; 
carbohydrates, 859; fat, 198; having a total fuel value of 6,079 calo- 
ries. The protein metabolised by these two contestants was found 
to be about twice as much as that metabolised by the average 
mechanic, and they did more than two days' work in one. Each 
contestant lost " body protein equivalent to two or three pounds 
of lean flesh, and that no injury resulted therefrom would seem 
to indicate that these men had stores of protein which could be 
metabolised to aid in meeting the demands put upon the body by 
the severe exertion, without robbing any of the working parts, and 
at the same time relieving the system of a part of the labor of diges- 
tion. Possibly the ability to carry such a store of available protein 
is one of the factors which make for physical endurance " (Atwater 
and Sherman). 

The dietetic training of jockeys is merely for the purpose of re- 
ducing weight, and more depends on their eating a small quantity of 
food than upon its restriction in variety. They should make their 
fare chiefly bread and meat, and abstain from much fluid. 

Chambers points out that men who have brief holidays in the 
country often fail to get the maximum good of their outdoor life, 
because they are not in proper condition for it. If a shooting or 
walking trip is to be undertaken for a week or two, it is well to ab- 
stain for a fortnight beforehand from eating elaborate dinners, and 
to leave off sweets and pastry and live on a drier diet than usual. 

In general the athlete in training, when not trying to reduce his 
weight, develops more energy from food and consumes more pro- 
tein than the ordinary working man. In the case of the crews 
studied by Atwater this excess of energy equalled 400 calories, or 
10 per cent, and the protein consumption was increased by 45 per 
cent. This excess of protein is demanded by the increased nervous 
tension which is lacking in the slow, methodical, muscular exertion 
of the day labourer (Zuntz). 

DIET AND OCCUPATION 

There are some occupations which are more or less closely con- 
nected with dietetics. Workers in lead, plumbers, painters, polish- 
ers, pottery glaziers, et ah, should be taught to be very careful to 
cleanse the clothing, hands, and especially their finger nails, before 



73^ 



RATIONS, DIETARIES 



The following Table, compiled by A. P. Bryant for the Yearbook of the 
U. S. Department of Agriculture for 1898, presents a Comparison of 
the Average Food Consumption of People of Different Occupations or 
in Different Conditions of Life 

(Per man per day) 



Families Studied. 



Average of 10 farmers' families in ) Yood 
Vermont. Connecticut, and New >- -^ , 
York.... \ Fo ° d 

Average of 14 mechanics' families ) p j 
in Connecticut, New Jersey, y y , 
Tennessee, and Indiana ) 

Average of 14 professional men's ) y , 
families in Connecticut, Penn- [-p 00 J 
sylvania, Indiana, and Illinois.. ) 

Average of 15 college clubs in ) -p j 
Maine, Connecticut, Tennessee, >• -p j 
and Missouri ) 

Average of above 53 studies < y , 

Average of 12 labourers' families [ Food 

in New York city \ Food 

Average of 11 poor families in ) Food 

New York city ) Food 

Average of 2 labourers' families, } Food 

very poor, in Pittsburg, Pa ) Food 

Average of 2 labourers' families, ) y _, 

more comfortable circumstances, y y _, 

in Pittsburg, Pa ) 

Average of 12 negro families in ) y , 

Alabama ) 

Average of 4 Italian families in ) y j 

Chicago, 111 ) 

Average of 5 French Canadian ) p OQ j 

families in Chicago, 111 ) 

Average of 4 families of Russian ) p OQ j 

Jews in Chicago, 111 ) 

Average of 8 -Bohemian families ) y , 

in Chicago, 111 ) 



purchased 
eaten .... 

purchased 
eaten 



purchased 
eaten. . . . 



purchased 
eaten. . . . 

purchased 
eaten .... 
purchased 
eaten .... 
purchased 
eaten .... 
purchased 
eaten .... 



purchased 
eaten .... 

purchased 

purchased 

purchased 

purchased 

purchased 



Cost. 


Pro- 
tein. 


Fats. 


Carbo- 

hy- 
drates. 


Cents. 


Grms. 


Gr?ns. 


Grms. 




IOI 


I36 


483 




97 


I30 


467 




no 


l6l 


425 


19 


103 


I50 


402 




108 


132 


429 


28 


104 


125 


423 




130 


187 


519 




107 


I48 


459 




113 


I 5 6 


463 




103 


138 


436 




103 


IIQ 


356 


iq 


IOI 


Il6 


344 




96 


98 


414 


15 


93 


95 


407 




81 


98 


3ii 


11 


80 


95 


308 




121 


148 


534 


19 


120 


147 


534 


9 


67 


134 


453 


16 


103 


in 


391 


22 


118 


158 


345 


19 


120 


IOI 


406 


12 


115 


IOI 


360 



Fuel 
value. 



Cats. 
3,655 
3,515 

3,690 
3,465 

3,435 
3,325 

4,390 
3,690 

3,810 
3,5oo 
2,95o 
2,905 
3,005 
2,915 
2,525 
2,485 

4,055 
4,045 

3,375 
3,060 

3,365 
3,095 

2,885 



eating. The soft crumb of bread getting under the nails easily be- 
comes contaminated with lead salts, which by this means are con- 
veyed to the stomach, where the white-lead carbonate, which is in- 
soluble in water, is dissolved by the gastric juice into a more dan- 
gerous chloride. Workers in dyestuffs, artificial flowers, green wall 
papers, and other materials in which arsenic is used, should be simi- 
larly careful, and should never be permitted to bring their food into 
the workrooms. 

Some occupations — those of foundrymen, stokers, and porcelain 
manufacturers — necessitate exposure to extremely high tempera- 
tures. Profuse sweating results, and thirst. The thirst is quenched 
by subsequently drinking enormous quantities of fluid, which should 
be water or oatmeal water, not too cold, rather than beer or other 



DIET FOR BRAIN WORKERS 737 

alcoholic beverages. Their lives at best are apt to be shortened by 
the suddenness and severity of the changes to which their kidneys 
and circulation are subjected, and a resort to alcohol is soon fatal. 

Tea tasters acquire more or less poisoning, although they do not 
swallow the beverage, for a good deal is absorbed by the mucous 
membrane of the mouth. The symptoms are insomnia, nightmare, 
headache, " nervousness," tremors, dyspepsia, and constipation. 
Even smelling the tea infusions constantly is poisonous to some 
sensitive persons (Chambers). To mitigate the danger they should 
eat abundantly before exposing themselves to the noxious effects of 
their occupation. 

Among other diseases occasioned by the handling of food prod- 
ucts may be mentioned the grocer's itch, from handling low grades 
of sugar (now much less common than formerly, owing to better 
methods of refining), and the bronchial diseases produced by 
the inhalation of flour and grain dust in grist mills and grain 
elevators. 

There are, in addition, many occupations which directly interfere 
with the proper digestion of food, such as those of tailors and shoe- 
makers, whose cramped positions compress the abdominal viscera 
and impede full respiratory action. Their discomfort from dys- 
pepsia and flatulency teaches them to avoid eating vegetables and 
sweets. 

All occupations conducted in close, ill-ventilated apartments are 
injurious by depriving the individual of sufficient oxygen to con- 
sume the food products in the system. 



DIET FOR BRAIN WORKERS 

Persons who are constantly employed in mental labour, and con- 
sequently lead sedentary lives, usually find from experience, sooner 
or later, that they must pay attention to their diet in order to main- 
tain the best condition of health. Energy diverted for mental work 
is apt to be at the expense of digestive activity, consequently it is 
important that the meals should be of such a character as not to 
unduly tax the stomach and intestines. As a rule, meat should be 
eaten but once a day, and then only in moderation, and persons who 
are not of strong physique do well to replace meat for a time by 
other varieties of animal food which require less time and energy 
for their digestion. Milk, eggs, fish, and abundant fresh fruit, 
with light, porous, and dry bread, should constitute their staple 
dietary. 

Brain workers may suffer from lithsemia, which is undoubtedly 
often due to other causes than dietetic errors, such as anxiety, worry, 
and overwork. Patients of this class do better with a good, full, 
nourishing diet than by any attempt at restriction, provided their 



738 RATIONS, DIETARIES 

food is thoroughly well cooked and is light and digestible. They 
should avoid saccharine, fatty, and purely starchy dishes, but they 
need meat, and may have a moderate variety of fruits and fresh 
green vegetables. 

The brain contains nearly three times as much fat as may be 
found in the muscles, and in nerves an even larger percentage is 
present. For this reason carbohydrates and fats are of value for 
brain workers who are not lithaemic, and the latter food may be 
supplied in the form of cream, butter, or fat well-cooked bacon. 

It is believed by some writers that the fact that fat is good food 
for brain workers depends upon the ease with which it develops 
energy with less complex metabolism than starches, and the nervous 
energy of many Americans is sometimes attributed to the greater 
consumption of fat in this country as compared with Continental 
Europe and England. 

The popular idea that fish has some specific action as a brain 
food on account of the phosphorus which is present in some species 
in considerable amount, and which is also an ingredient of nerve 
tissue, is not founded upon fact. Fresh fish is very wholesome, and 
by replacing meat in the menu less labour is required of the digestive 
organs, and some forms of fish contain abundant fat or oil, but aside 
from this, fish cannot be said to be especially a brain food. It has 
been pointed out elsewhere (p. 124) that the tribes of man who live 
very largely upon fish are by no means noted for their intellectual 
development. 

For brain workers who desire to keep in good health the alterna- 
tive is either to take at least two hours of rest after a noon dinner 
or else to eat a light meal at noon and dine later in the day. This 
fact should be recognised in the arrangement of meals for college 
students. It is far better during the active hours of brain work 
to supply only such food as is necessary for prompt force produc- 
tion without calling upon the digestive organs for the expendi- 
ture of much energy in elaborating food which is only needed for 
storage. 

Breakfast should consist of fresh fruit, a cereal with cream, a 
poached Qgg, a bit of broiled (not fried) fish, or a rasher of bacon, 
with tea or coffee. 

Luncheon may comprise such articles as a roast potato with butter 
and cream, or beans and bacon, one or two light sandwiches made 
with a slice of game or a relish of some sort, cheese, lettuce or salad, 
and a baked apple and cream. 

Dinner should be a hearty meal with soup, a roast or joint, vege- 
tables, and a light farinaceous pudding. If evening w T ork must be 
done, there should be an interval of at least an hour for rest and 
recreation. A generous meal is easier digested after work is done, 
and makes the best preparation for the next day's toil. 



DIET FOR BRAIN WORKERS 



739 



A Work Ration for a Professional or Literary Man 
(Mrs. E. H. Richards) 



Ounces. ! Protein. 



Fats. 



Carbo- 
hydrates. 



Calories. 



Bread.. 

Meat 

Butter 

Sugar 

Milk 

Oysters . , 

Soup 

Potatoes 

Eggs... 

Oatmeal 

Cream 

Fruit 

Additional liquid — tea, coffee, or water 



Total. 



16 
16 

i 

4 

S 

4 
4 
6 

3 

2 

I 

8 

3o 



Grammes. 
32.O 
50.0 



I8.0 
7.0 
4.O 
3.0 

IO. O 
I .O 
1-5 
0.5 



Grammes, 

3-o 
30.0 
25.0 

18.0 
1.0 
3-o 

9.0 

0.5 
6.5 



127.0 



96.0 



Gram?nes. 
258.O 



IIO.O 
22.0 



38.0 
4.O 

1.0 
50.0 



483.0 



1,216.6 
481.0 
230.0 

451.0 
^29.6 

37.8 

44.0 
168. 1 

123.8 
25.1 
70.1 

207.1 



3,384.2 



Overeating should be studiously avoided. Loading the system 
with incompletely assimilated food products impairs intellectual 
activity and exhausts the nervous system. If some special task 
requires long hours of work and absorbing concentration, it may 
be better to eat but little at a time, and take one or two extra lunches 
during the day. When such labour proves fatiguing, alcohol may 
be temporarily employed, but only with the meals, and not as a 
stimulant between. The quantity may be regulated somewhat by 
the appetite, but it should never be large. If a glass or two of claret 
or Burgundy or of malt liquor with lunch or dinner improves the 
appetite for solid food and aids its digestion, it is beneficial, for, as 
Chambers wrote, " it stays the weariness of the system and allows 
the nerve force to be diverted to the digestion of the meal " but to 
labour on and " continue to take this anaesthetic between meals is 
inconsistent " ; and " when any extraordinary mental toil is tem- 
porarily imposed, extreme temperance or even total abstinence 
should be the rule, for mental activity makes the brain bear less 
alcohol than rest and relaxation." 

The varieties of beverages named are all better than port, sherry, 
or the stronger liquors. 

It is a mistake to suppose that violent muscular exercise is an 
offset to mental strain. Very moderate exercise combined with 
abundant fresh air and with mental diversion and relaxation are 
more beneficial, and do not add one kind of material exhaustion 
to another already present. 

Tobacco and coffee, like alcohol, are stimulants which are use- 
ful in such cases only in proportion to the moderation in which they 
are employed. Tea may be allowed in the earlier part of the day 
if it does not cause wakefulness. 



740 RATIONS, DIETARIES 

Following is the dietary at the Lake Erie College, at Painesville, 
Ohio, for women students : 

DAILY MENU 
Wednesday, January ij, 1900. 
Dinner. — Corned beef, mashed potatoes, turnips, bread, butter, 
rice pudding. 

Thursday, January 18. 

Breakfast. — Baked apples, hominy grits, creamed dried beef, 
bread, butter, milk, coffee. 

Luncheon. — Cheese, pudding, raspberry jam, bread, butter, milk, 
tea. 

Dinner. — Roast beef, potatoes, parsnips, bread, butter, chocolate 
pudding. 

Friday, January ip. 

Breakfast. — Oranges, wheat breakfast food, corned-beef hash, 
corn rolls, butter, milk, coffee. 

Luncheon. — Oyster stew, wafers, bananas, bread, butter, tea. 

Dinner. — Pot roast, potatoes, beets, bread, butter, brown betty, 
lemon sauce. 

Saturday, January 20. 

Breakfast. — Wheat breakfast food, bacon, baked potatoes, bread, 
butter, milk, coffee. 

Luncheon. — Beef in gravy, pickles, sauce, milk, bread, butter, tea. 

Dinner. — Lamb chops, potatoes, canned peas, bread, butter, 
cherry tapioca, cream. 

Sunday, January 21. 

Breakfast. — Oranges, wheat breakfast food, fried mush, maple 
sirup, bread, butter, milk, coffee. 

Luncheon. — At evening on Sunday. Stewed apricots, cake, milk, 
tea, bread, butter. 

Dinner. — Stewed chicken, mashed potatoes, cranberries, bread, 
butter, cottage pudding, hard sauce. 

Monday, January 22. 

Breakfast. — Bananas, wheat breakfast food, rolls, codfish balls, 
bread, butter, milk, coffee. 

Luncheon. — Beet salad, raspberry jam, milk, bread, butter, tea. 

Dinner. — Hamburg steak, browned potatoes, squash, bread pud- 
ding. 

Tuesday, January 23. 

Breakfast. — Hominy grits, minced lamb, milk, bread, butter, 
coffee. 

Luncheon. — Pea soup, crackers, bananas, tea, bread, butter. 



DIET IN COMMERCIAL LIFE 741 

Dinner. — Roast pork, baked sweet potatoes, cole-slaw, bread, 
butter, dates. 

Wednesday, January 24. 

Breakfast. — Bananas, hominy grits, bacon, potato cakes, bread, 
butter, milk, coffee. 

Luncheon. — Baked beans, brown bread, pickles, milk, bread, but- 
ter, tea. 

Dinner. — Roast beef, boiled potatoes, spinach, bread, butter, 
boiled rice, maple sirup. 

Thursday, January 25. 

Breakfast. — Oranges, wheat breakfast food, meat hash, French 
toast, bread, butter, milk, coffee. 

Luncheon. — Cheese, gingerbread, bread, butter, cocoa. 

Dinner. — Beefsteak, mashed potatoes, Lima beans, bread, butter, 
baked potatoes. 

Friday, January 26. 

Breakfast. — Cream of wheat breakfast food, creamed beef, rolls, 
bread, butter, milk, coffee. 

Luncheon. — Pea soup, croutons, apple butter, bread, butter, tea. 

Dinner. — Baked ham, catsup, stewed tomatoes, potatoes, bread, 
butter, fruit custard. 

Saturday, January 27. 

Breakfast. — Oranges, wheat breakfast food, beef in gravy, bread, 
butter, milk, coffee. 

Luncheon. — Boiled rice, stewed prunes, milk, bread, butter, tea. 

DIET IN COMMERCIAL LIFE 

The responsibilities and anxieties of active business life are apt 
at times to react unfavourably upon digestion, producing dyspepsia, 
headache, constipation, and biliousness. As a rule, there are few 
patients less willing to listen to advice in regard to diet and habits 
of life than the overworked business man engaged in the strife of 
active competition and with large financial interests at stake. He 
expects a dinner pill or laxative or the latest fashionable " tonic " 
to counteract the persistent violation of the simplest dietetic and 
hygienic laws, and, obtaining temporary relief, goes on overtaxing 
his alimentary canal, liver, and nervous system, laying the founda- 
tion of more serious ills, such as lithsemia, arterio-sclerosis, or possi- 
bly gout, gravel, or cirrhosis. The prevalence of chronic Bright's 
disease and neurasthenia in this country is by some clinicians of large 
experience attributed to such causes. Imperfectly oxidised waste 
materials in the circulation may irritate kidneys and vascular system 
alike, and long-continued excitation eventually results in structural 
changes. 



742 RATIONS, DIETARIES 

While prescribing remedies for individual symptoms the physi- 
cian should not neglect to give wholesome counsel concerning diet, 
and such advice, however little heeded by itself, will sometimes be 
regarded as an essential part of other remedial measures, and ac- 
cepted accordingly. The too hasty consumption of food, the neglect 
of securing proper action of the bowels, and carrying the concerns 
and worries of the counting-house to the table, combined with loss 
of sleep and of outdoor exercise, are the principal difficulties which 
this class of patients must contend against. Three good meals a 
day should be eaten. The breakfast should be substantial, compris- 
ing meat or eggs or fish with some cereal and fresh fruit ; and dinner 
should be the last meal of the day, eaten preferably late — at half past 
six or seven o'clock — allowing an interval before the meal for recre- 
ation or diversion. 

The lunch should be the lightest meal of the day, for the reason 
that it is difficult for many to take it always at a fixed hour, and still 
more difficult to allow sufficient time for due mastication and diges- 
tion. Sydney Smith once said, referring to the bad habit of hasty 
eating, that " many a man digs his grave with his teeth." It is not 
necessary, nor is it advisable, to eat meat three times a day, and 
many of these patients who are made dyspeptic by eating meat and 
vegetables together find that they have less flatulence and discom- 
fort after meals if they take these classes of foods independently, 
eating meat and no vegetables or sugars at one meal, and vege- 
tables without meat at another. The reason for this should be ex- 
plained to them — namely, that carbohydrates, digested only by alka- 
line saliva and pancreatic fluid, may interfere with the acid digestion 
of animal food in the stomach. The luncheon should consist, there- 
fore, of simple farinaceous food with one or two plainly cooked vege- 
tables or a salad and a relish of some sort. 

Alcoholic stimulants of any kind are not required, except to 
counteract exceptional fatigue, and, as a rule, these patients are 
better without their habitual use. If allowed, they should be drunk 
at dinner only. Malt liquors taken at luncheon are apt to cause 
drowsiness and dulness in the afternoon. 

As adjuncts to the dietetic treatment other measures should not 
be neglected. Cold bathing with vigorous rubbing is desirable on 
rising, and an occasional Russian or Turkish bath may be service- 
able if there is a tendency to heavily loaded urine and biliousness. 
Exercise in the open air is very important. Golfing is of value, but 
too much walking is fatiguing. Bicycling is much better. It fur- 
nishes more active exercise and diverts the mind ; but horse- 
back riding is preferable, even if it can be indulged in but once 
a week. 

The bowels should be kept active, and fresh fruit and abundant 
draughts of pure water are the best means for this purpose. 



DIET AND TRAVEL 743 



DIET AND TRAVEL 



In travelling one is often placed in circumstances in which it is 
difficult or impossible to obtain wholesome food, and must either be 
content with badly cooked or positively repugnant food, or go with- 
out. Under such conditions it is a decided advantage to have a 
varied taste, so that something may be found which will not disgust. 

It is difficult to give any but the most general directions for 
circumstances which are so various. It is a common fault to eat too 
much when travelling, and the lack of exercise combined with an 
excess of food results in indigestion, constipation, and biliousness. 
Sea voyages sometimes benefit invalids and dyspeptics more than 
the healthy, for the latter, if not seasick at first, often overeat, and 
suffer in consequence. 

The " stand-up lunch counters " of American railway stations 
freighted with doughnuts, tough ham, and pie are a constant invi- 
tation to dyspepsia with the hurried eating of such indigestible arti- 
cles as they afford, but which the more general introduction of din- 
ing cars is fortunately replacing, at least for those whose means 
allow them to consult the best interests of their digestive organs. 

In warm climates olive oil may be often obtained and made to 
replace rancid butter upon baked potatoes. Much garlic may cause 
diarrhcea and colic in those unaccustomed to its use, but mustard 
will counteract its effect. Lemon juice also forms a wholesome 
relish and aids in checking diarrhoea. It is well to avoid raw or 
imperfectly cooked ham and sausage of every sort, for fear of para- 
sitic infection. If the food is inevitably greasy its digestion may be 
promoted by the use of condiments, such as vinegar, Cayenne, or 
lemon juice. All milk as well as water drunk should be previously 
boiled. 

Fresh fruits, crackers, bread, cold meats, soft-cooked eggs, and 
milk will be found to comprise the most digestible articles for a 
railway journey, and invalids or travellers who have wandered far 
from good food supplies do well to carry some of the concentrated 
preparations which with the aid of a little hot water may be made 
into a nutritious beverage, such, for example, as malted milk and 
cereals, beef meal or beef jelly, chocolate, condensed coffee, meat 
extracts, etc., besides which there is an almost inexhaustible variety 
of canned foods, meats, vegetables, and fruits from which the trav- 
eller or explorer may replenish his table. For infants sterilised 
milk may be carried which will keep fresh for ten days, or canned 
milk may be provided for a longer period. 

Lime tablets are prepared which may be conveniently used in 
travelling when fresh lime water is likely to be required for dilution 
of milk or for use in seasickness. 
49 



744 RATIONS, DIETARIES 



DIET IN PREGNANCY 

It is not customary to adopt any definite system of diet for preg- 
nancy unless complications arise. If serious vomiting occurs in the 
early months, this should be treated in the manner described on 
p. 543. If albuminuria is discovered, meat and other nitrogenous 
food must be restricted, in accordance with the directions given 
under albuminuria (p. 496). If the patient becomes very anaemic, 
without albuminuria, meat, eggs, and milk should be eaten in abun- 
dance (p. 486). 

The " longings " of pregnant women for various indigestible 
articles, such as pickles, chalk, etc., are largely mythical, and occur, 
if at all, only as an accompaniment of a general hysterical con- 
dition, not as a peculiarity of the period of pregnancy. Pregnant 
women, however, should live simply and avoid foods which are 
likely to produce dyspepsia, heartburn, and colic, such as sweets, 
pastry, fried food, rich sauces, spiced dishes, and heating drinks. 
They often suffer from constipation, in which case fruits and coarse 
cereals, such as oatmeal or wheaten grits, may be of service (p. 571). 
The stomach, especially at night, should not be overloaded. 

The idea formerly prevalent that pregnant women need to eat 
food containing abundant phosphates and lime salts, to furnish the 
embryo with material for making bones, as a hen eats lime to make 
egg shells, is no longer accepted. The salts in question are suffi- 
ciently contained in an ordinary mixed diet, such as any pregnant 
woman may eat, if plainly cooked. 

Another theory, equally ingenious and directly opposed to the 
one above mentioned, is only interesting historically, for efforts to 
aid Nature in a process which she is abundantly competent to regu- 
late unaided are: now regarded as futile. This theory was that the 
agonies of labour would be less severe if the pregnant woman lived 
upon a diet of fruits and meats, avoiding bread and fresh vegetables 
during gestation, on the ground that the lime salts which they con- 
tain would favour early ossification of the infant's bones, and thus 
make the labour proportionately difficult. 

It will be observed that the first theory favours the child, and 
the second the mother, but practically it has been found that diet 
has little or no influence either way, so long as it is digestible, 
nourishing, and sufficient to keep the mother in good general con- 
dition. 

DIET FOR PUERPERAL WOMEN 

Within the past thirty years a revolution has been experienced 
in the dietetic treatment of puerperal women, and they are no longer, 
as formerly, kept for ten days or a fortnight upon a diet of toast 
water, " slops," etc., with the idea that semistarvation would keep 



DIET FOR PUERPERAL WOMEN 745 

down puerperal fever and " milk fever." This change is largely 
due to methods of antiseptic midwifery, but the reaction started 
even earlier, and in 1876 Fordyce Barker, who was one of the first 
to forsake the old routine, wrote of the puerperal state : " I have 
never seen the slightest evil result from good, ample, judicious ali- 
mentation," and " I have had patients eat a good piece of tenderloin 
steak the day after labour with a relish, and with happy results." 

A pregnant woman may eat her ordinary diet up to the com- 
mencement of labour. 

If the labour is greatly protracted, the first stage lasting, as it 
exceptionally does, for more than a few hours, it will not do to let 
her strength become further exhausted from lack of food, and she 
must be urged to take stimulating hot broths, gruels, or similar 
easily digested food. Under the circumstances she is naturally 
nervous and may decline all food, so she should be given only that 
which is quickly swallowed without effort. In ordinary cases, how- 
ever, no food is necessary or desirable during labour. 

Immediately after delivery the woman, exhausted by muscular 
effort and agonising pain, and possibly also under the influence still 
of an anaesthetic, needs rest rather than food, and as she is more 
thirsty than hungry, she may drink freely of water or Vichy. 

On the other hand, many puerperal complications, including 
mania, are favoured by exhaustion and inanition, and good feeding 
must not be delayed too long. The nursing woman, moreover, 
needs a more liberal diet than other patients. Her milk contains a 
large percentage of proteid and fat, and she also loses proteid sub- 
stance to a greater or less extent through the lochia. A low diet 
means poor breast milk, for it diminishes both its fats and proteids. 

Spiegelberg says : " It is a bad practice to allow healthy lying-in 
women to fast long; they need to be well fed, and if the appetite 
is good they may be encouraged to eat." If they are well nourished 
they both sleep and feel better. " Four or five hours after con- 
finement the patient may be given a cup of hot bouillon or chicken 
or mutton broth. She usually does not care for meat before the 
second or third day, but she may have it then. Meanwhile she is 
allowed broths of any kind, thickened with egg or rice, milk, tea, 
light farinaceous gruels or puddings, soft-cooked eggs, toast, milk 
toast, custards." Schroder gives meat and vegetables within a day 
or two after the conclusion of labour. Lusk recommended a light 
fluid or semisolid diet for the first three days. Then, after the bowels 
have moved once or twice and the appetite returns, steak, chops, 
a piece of fowl or a bird, eggs, and cooked fruits are given. 

Playfair adopted the following system : If the woman is confined 
in the early morning hours, at 9 A. m. she is given a cup of tea and 
a piece of toast ; at 1 p. m. a light lunch of some form of predi- 
gested meat preparation ; at 5 p. m. tea or beef tea, and at 7 p. m. a 



■ ■ 



74-6 RATIONS, DIETARIES 

small bit of chicken with bread and butter or milk toast. Tea again 
at 9 p. m. He discountenanced a continued use of gruels, " slops," 
and stimulants. During the next day or two if the patient is hungry, 
he allowed sweetbread, chicken, fish, eggs, and milk. 

On the whole, the patient's own appetite is a better guide for 
feeding than are any rules as to the exact time which has elapsed 
since parturition. She should not be urged to take food, unless 
greatly exhausted, and the stomach must not be overloaded; but if 
hungry after the establishment of the milk secretion and after free 
action of the bowels, she may be allowed a reasonable quantity and 
variety, though while, still in bed she needs less than if up and 
about. The occurrence of fever is a contraindication for giving 
much proteid food except milk, but extreme exhaustion without 
febrile reaction demands it. 



SELECTION OF A WET NURSE 

The selection of a wet nurse should be based upon the following 
data: 

Her own general health and digestion must be good, and her 
bowels not habitually constipated. All evidence of syphilis, scrofula, 
tuberculosis, or other disease must be rigidly excluded. A primip- 
ara is to be preferred to a multipara as having milk somewhat 
richer in fat. 

Her best age is between twenty-two and thirty years, and she 
should be of good temperament and have cleanly habits. Her period 
of lactation should not be too widely different from the age of the 
infant to be nursed. 

The breasts should be firm, and the nipples fairly prominent 
and free from fissures. Breasts which are always oozing sponta- 
neously are by no means always the best, for their milk is soon 
exhausted. 

The nurse's own child, if living, should be examined, for if it has 
been nursing at the breast its condition is an even better index of 
suitableness of the mother's milk than her own appearance. 

The child should be in good flesh and firm, without evidence of 
gastric catarrh, fever, or indigestion, and of good development for 
its age. 

The question whether it is possible for a wet nurse to transmit 
her own mental and physical characteristics to the child at her 
breast has given rise to much discussion, but there is no more reason 
why she should transmit an evil temper through the food she gives 
than that a cow should transmit a bland one. An ill-tempered, iras- 
cible wet nurse may sometimes give milk which disagrees with the 
child's stomach, but beyond that there is nothing in the belief that 
she can affect it mentally or morally by this agency. 



DIET OF A NURSING MOTHER OR WET NURSE 



747 



The milk which can be expressed from the breast should have 
the following properties : Reaction alkaline, color an opaque blue- 
white, specific gravity 1.03 1, taste sweetish. Examined microscop- 
ically, the fat corpuscles should abundantly fill the field and be of 
nearly equal size. 

Human breast milk on an average has a specific gravity of 1.031 
at yo° F., but it varies between 1.017 and 1.036 (Holt). The fat 
varies less than the sugar and proteids. 

If the specific gravity of the milk is high, and at the same time 
the percentage of fat is considerable, the gravity must be due to a 
larger quantity of proteids than usual, because fat tends to lower it. 
If the fat percentage is small and the specific gravity of the milk is 
low, the proteids must also be reduced. Holt furnishes the follow- 
ing convenient table for determining the richness of human milk in 
fats and proteids, which gives results that are sufficient for practical 
purposes in examining the milk of a wet nurse : 





Specific gravity 

7 o°F. 


Cream — 24 hours. 


Proteids — (calculated). 


Normal average. . . . 


1. 031 


7% 


1-5* 


Healthy variations. . 


I.028 — I.029 


Sfc—12% 


Normal (rich milk). 


Unhealthy " 


I.O32— I.O33 

Below 1 .028 
14 t< 


High (above io£). 
Normal (5% — io#). 


" (fair milk). 
" or slightly below. 
Low. 


« :: 


Above 1.033 


Low (below 5#). 

High. 

Normal. 


Very low (very poor milk). 
Very high (very rich milk). 
High. 


" •• 


" " 


Low. 


Normal (or nearly so). 



To calculate the actual fat from the cream multiply bv three 
fifths. 

In examining the composition of the milk of a wet nurse it is 
only fair to the nurse to remember that, like cow's milk, her own 
contains less fat when the milk is first drawn than after the breast 
has been nursed for a few moments. 

The quantity of the milk may be best estimated by weighing the 
infant immediately before and after suckling, when the gain should 
be between three and six ounces. 



DIET OF A NURSING MOTHER OR WET NURSE 

The diet of the nursing mother or wet nurse must be regulated, 
to prevent noxious substances from passing into the breast milk and 
to keep her in good health, so that she does not suffer from consti- 
pation, indigestion, or anaemia. Her weight should not alter, and 
if she has menstruated once or twice the milk changes and may 
disagree. 

If milk does not make her constipated or bilious she may drink 



748 RATIONS, DIETARIES 

it abundantly. She may take gruels and meat broths, and she should 
eat simple nourishing food, meat, eggs, vegetables, and fruits. The 
latter, even if sour, do not react unfavourably upon the child, pro- 
vided the mother's digestion is good, and they serve to keep the 
child's bowels active. The mother should forego the drinking of 
much tea and coffee. Beer and wine also should not be drunk unless 
they are especially prescribed as a tonic. Wet nurses often demand 
beer, ale, or porter with their meals if they have been accustomed to 
it ; but the popular idea that such beverages are especially beneficial 
is fallacious. Malt liquor sometimes causes the secretion of more 
milk, because more fluid is drunk, but the milk is no better for it. 
A reasonable quantity of fluids should be drunk, however, or the 
secretion of milk will suffer. The fluid may be in the form of plain 
or effervescing water, milk, soups, etc. 

The mother or wet nurse should avoid all fatigue, worry, and 
emotional excitement of any kind, which may inhibit her digestive 
functions, and should take daily outdoor exercise. 

On the whole, the best indication for the dietetic treatment of 
the wet nurse is the study of the condition of the child's digestion, 
bowels, and nutrition. A too meagre diet for the nurse is soon evi- 
dent in lack of nutrition and development of the infant. 

Drug's in Human Milk. — Not many drugs pass unchanged into 
the milk which are likely to poison the child through its food, 
but there are some which should be carefully avoided on this 
account. Such are belladonna, opium, morphine, and other alka- 
loids ; iodine and its preparations ; mercury and its salts ; salicylic 
acid (see p. 57). 

When, for any reason, it becomes necessary to discontinue the 
nursing and to stop further secretion of milk, the diet should at 
once be made as dry as possible, and a minimum quantity only 
of fluid is allowed. 



THE FOOD OF INFANTS 

Size of the Infant's Stomach. — With regard to infant nursing, 
it is never sufficient to give general directions about an infant's 
food. The physician should supervise the exact mode of its prepara- 
tion, and order both the quantity to be given and the intervals at 
w 7 hich it is to be given. 

Mothers seldom know what is best for their infants in these 
matters. 

It is therefore well to explain to them fully the facts as to the 
proper hours for feeding and the amount of food required, and also 
to give them some idea of the size of the infant stomach, for many 
have a vague idea that the word " stomach " includes almost the 
entire abdominal cavity. 



THE FOOD OF INFANTS 749 

Rotch gives the following table of capacities of infant stomachs : 

i. Premature 8 months' infant 8 cubic centimetres. 

2. Infant 5 days old 2 5~30 ' ' 

3. Infant 4 weeks old 75 " 

4. Infant 8 " " 96 " 

5. Infant 16 " " 107 " " 

6. Infant 20 " " 108 " " 

It is advisable to show the mother or nurse an empty bottle 
representing the capacity of the infant's stomach, in order to im- 
press upon her the danger of overloading it. 

Overfeeding. — It is sometimes said that overfeeding kills more 
babies than starvation, and certainly it is responsible for a large 
proportion of the ailments of early infancy, such as gastric catarrh 
and diarrhoea. This is especially true in summer, when the fretful- 
ness of the child, which is often mistaken for hunger, may be due to 
thirst, the external temperature, too warm clothing, or indigestion. 
At such times Holt advises reducing the bulk of each meal by one 
quarter and giving the infant more water to drink, for, as he says, 
infants, like adults, require less food in excessively hot weather. 

It is difficult to impress mothers with the fact that milk should 
never be given to soothe a baby's fretfulness merely, and " un- 
methodical and improper feeding is quite as bad as feeding with 
improper aliments " (Adams). 

The young infant secretes no ptyalin to digest starch, and Biedert 
finds that the infant stomach does not well digest albumin when its 
solution is stronger than 1 per cent. 



Methods of Feeding 

Infants may be given their food in one of five ways: I. By 
mother's milk. II. By milk from a wet nurse. III. By bottle feed- 
ing. IV. By mixed feeding — i. e., when the mother's or nurse's 
milk is supplemented by bottle feeding. V. By gavage. 

There is no room for doubt that infants brought up on breast 
milk are stronger and better able to remain in good health and 
resist disease than those who are hand fed, for no infant food has 
ever been devised which is in every way as satisfactory as good 
mother's milk. 

This method is unquestionably better for the infant in all cases 
where it is feasible 'than any method of artificial feeding. In lands 
without cow's milk, such as Japan or the arctic regions, infants are 
singularly free from digestive disorders. Artificial feeding, if care- 
lessly performed, is full of dangers to the infant. Statistics might be 
cited indefinitely, showing the relative high mortality rate among 
artificially fed infants. For example : In Munich, the mortality rate 



750 RATIONS, DIETARIES 

has been 15 for breast-fed infants, against 85 for those artificially 
fed ; and in England, 42 per cent of the infant mortality is due to 
digestive disorders, largely among the artificially fed. 

I and II— FEEDING BY THE MOTHER OR WET NURSE 

Starr advises putting the infant to the breast as early as six or 
eight hours after labour is completed, which is good for both mother 
and child. For the mother it improves the nipple, stimulates the 
true milk secretion, and reflexly the uterine contractions ; for the 
infant it is also desirable, for it insures the ingestion of colostrum. 

Colostrum constitutes the secretion of the first three days. This 
secretion is mildly laxative, and it cleanses the child's alimentary 
canal of the waste matter called meconium, which is found within 
it at birth. 

Colostrum contains an excess of albumin, so that boiling coag- 
ulates it. It also has large corpuscles, which may be seen with the 
microscope throughout the first week of lactation, gradually lessen- 
ing in number. They then rapidly disappear, and none should be 
present after a fortnight. If found later, the milk is certain to dis- 
agree and a change of nurse is necessitated. 

Intervals for Feeding. — Infants during the first three days should 
be nursed only four or five times a day. Water may be given, but 
no bottle food, which only upsets the stomach and lessens the 
ability to suck. After this period once every two hours is the proper 
interval for suckling for the first six weeks or two months. The 
child should be nursed at this interval between 5 a. m. and 11 p. m., 
with one feeding only in the middle of the night. If absolute regu- 
larity is always observed in the hours for nursing, the child's digest- 
ive organs keep in much better condition, it sleeps better, and is 
much less likely to be overfed. During the first four or five months 
of life an infant should be fed once during the night ; after that it 
need not be fed between 10 p. m. and 7 a. m. When a year old, if 
strong and well, it need not be fed between 7 p. m. and 7 a. m. If 
fed or nursed oftener than this, the child receives too much food, 
and digestion and rest are both disturbed. 

Sometimes an infant will demand milk at night and not take it in 
the daytime as well as it should, but with a little firmness and by 
starving it for a few hours until it is really hungry, it can often be 
trained to suckle in the manner which experience has proved is best 
for both itself and its mother. 

From fifteen to twenty minutes is sufficient time to keep the 
child at the breast, and it will often doze off to sleep after nursing. 

As the child grows older the intervals between the hours of 
nursing are to be prolonged, in accordance with the tables given 
below (pp. 756, 757), and the child may be allowed to remain a few 
moments longer at the breast. 



THE FOOD OF INFANTS 751 

The infant while sucking should always be held in a comfortable 
position with the nipple within easy reach. 

After a three-hour interval for feeding has been reached, it may 
be maintained in many cases until lactation is completed, but after 
reaching six months of age some infants do better with a three and 
a half or four hours' interval. 

Infants. born with a cleft lip or palate cannot be properly nursed 
at the breast, for they are unable to make the necessary vacuum in 
the mouth to draw the milk. They may be unable to take the bottle 
successfully, and must then be fed by gavage or with a spoon. 

Ill— FEEDING BY THE BOTTLE 

When it becomes necessary to employ artificial feeding there are 
two principles upon which it may be conducted. The first and most 
extensively practised is to endeavour to obtain a food by modifying 
cow's milk, which corresponds as nearly as possible to the composi- 
tion of average human milk. The second is to adapt the prepared 
milk to the needs of each particular infant, as suggested by the 
state of its digestive organs and existing nutrition and development. 
The first method seeks to bring the child up to the standard of the 
milk, the second to bring the milk to the standard of the child. 
This system of " prescription writing " as applied to milk, in cases 
of severe illness and great impairment of digestion, is more rational 
than the older method, but it presupposes much experience and care 
on the part of the physician. 

Due regard must be had, of course, for the circumstances of 
those for whom an especially modified diet is ordered. For the very 
poor, milk is a serious item of expense, and cream and sugar may be 
out of the question. Condensed milk is usually cheaper in large 
cities than fresh cow's milk, for less care and expense is involved 
in its transportation, and it is accordingly much used by the poor. 
Moreover, in hot weather it keeps without ice, but for reasons given 
elsewhere (p. 93) it is never to be preferred when good fresh cow's 
milk is obtainable. It is deficient in protein, and this may be cor- 
rected by adding meat broth, beef juice, or egg albumin. It is also 
deficient in fat, and cod-liver oil may be added. 

Cow's milk contains approximately half the quantity of sugar 
present in human milk. 

Leeds says that the curd derivable from human milk is only one 
fifth as much as that of cow's milk, and there are other striking 
differences in regard to the quantity of casein precipitable by acid, 
as compared with the non-coagulable ingredients of both forms of 
milk. 

For this reason cow's milk must be diluted for very young infants 
with two parts of water, in order to bring the casein nearer to the 



752 RATIONS, DIETARIES 

right proportion ; but the addition of water reduces the percentage 
of fat and of sugar. 

Escherich has shown that the infant fed upon diluted cow's milk 
has to take much more fluid than when nursed by breast milk to get 
the same quantity of nutriment, with consequent distention and pos- 
sible enfeeblement of the stomach. 

The disproportion of fat may be counterbalanced by using " top 
milk " — i. e., the upper layer which forms after the milk has stood 
for about eight hours, and which contains most of the cream. Milk 
sugar is then to be added in the proportion of one heaping teaspoon- 
ful to four ounces of the diluted milk. If cane sugar is used, which 
is less desirable, as it is more apt to ferment, only one teaspoonful 
to every six ounces is necessary. 

From a quart of ordinary milk six ounces of top milk may be 
skimmed, seven ounces from rich, and five from poor milk. In lieu 
of top milk a mixture of equal parts of cream and of ordinary milk 
should be used (Holt). 

When the milk causes dyspepsia, and large curds are vomited, 
it is well to substitute barley water for plain water in the same 
proportion. 

If pearl barley is used it should be boiled a long time — for six 
or eight hours — the water being replaced as it evaporates. The 
proportion usually employed is two tablespoonfuls of barley to the 
quart of water. After careful straining through a linen cloth, a pinch 
of salt is added, and when cool the fluid is ready for use. Instead 
of pearl barley, one of the barley flours may be employed. This 
answers the purpose as well, and has the advantage of requiring 
much less time, boiling for half an hour being sufficient. 

Holt gives the following formulae for an infant two months old 
receiving twenty-four ounces a day : 

Top milk. 8 ounces. 

Barley water 16 " 

Milk sugar 6 heaping teaspoonfuls, or 

Cane sugar 4 " " 

The quantity is to be slightly increased, but the proportion may 
remain the same until the seventh or eighth month, when the mix- 
ture should be changed to — 

Top milk 19 ounces. 

Barley water 19 " 

Milk sugar 9 teaspoonfuls, or 

Cane sugar 5 " 

In answer to the question, " Can a child one year old take plain 
cow's milk?" Holt says: "Many children can, but the majority do 
better when the milk is modified by the addition of cream and water, 
or by the use of diluted top milk. After standing six hours six 



THE FOOD OF INFANTS 753 

ounces should be taken off from the top of the milk bottle and ten 
ounces more should then be poured off and the two mixed. This 
may be diluted with an equal quantity of water or barley water." 

It is generally conceded that fresh raw cow's milk derived from 
a healthy cow, and carefully kept from germ contamination, is a 
more wholesome food for babies than milk which is either boiled, 
sterilised, Pasteurised, or peptonised. But in cities always, and 
everywhere in summer, it is difficult or impossible to obtain such 
milk, and one or other of the means of disinfection becomes im- 
perative. 

The heat required for sterilisation in some manner destroys the 
vital properties of nuclein of the milk (Starr). 

Peptonised milk is used much less for infant feeding than for- 
merly, for it has been found that they do not thrive if continuously 
fed upon it. 

Care of the Milk. — In order to keep milk fresh and pure for 
infant use in hot weather it should be at once artificially cooled, and 
if intended for city consumption, during transportation both car and 
delivery wagon should be supplied with ice, so that the milk tem- 
perature never rises above 50 F. The milk when received at the 
dealer's should also be kept in refrigerators, for it is exceedingly 
important that it should not become lukewarm even temporarily. 
It is an undoubted advantage to have the whole system of milk 
supply under proper inspection and licensing. The cows when 
stabled should be kept in clean, well-ventilated quarters, and should 
always have the udders washed before milking. Every receptacle 
used for holding the milk should be thoroughly scoured with boiling 
water each day, but after first rinsing with cold water. If this pro- 
cess is reversed, particles of scalded milk may cling to the pail or 
can and give rise to subsequent fermentation. Milk should never 
be allowed to stand about in uncovered vessels, especially in a bath- 
room, near an open sewer pipe or drain, or in a damp cellar. 

When given to the infant the milk, as well as all infant food, 
should be moderately warmed to approximate its bodv temperature 
(99° F.). 

When the milk temporarily disagrees it becomes necessary to 
substitute for it some other form of food. Useful formulae for this 
purpose are given by Starr as follows : 

Substitutes for Milk in Infant Feeding (Starr) 

Veal broth [\ lb. of meat to the pint) f 3 jss. 

Barley water f § jss. 

Mix. 

'. each, one and a half 

Barley water, ^ 

Milk sugar half a drachm. 

Give one portion at two months. 



ounce. 



754 RATIONS, DIETARIES 

Raw beef juice (one teaspoonful every two hours) will " be re- 
tained when everything else is rejected." 

Both barley water and lime water are sometimes added when 
temporary looseness of the bowels occurs. 

In using lime water (carbonate of lime) as a diluent of cow's milk 
in infant feeding, it should be remembered that in the latter the 
phosphate of lime is four times greater in quantity than in human 
milk (Leeds), and it is of questionable utility to continue the practice 
beyond the requirements of a temporary fit of indigestion. 

Many persons suppose that the milk from a single cow is to be 
preferred to the mixed milk of several animals, and formerly some 
dairies used to supply such milk in separate bottles. It has been 
proved, however, that there is less variation in the quality of mixed 
milk, and the infant is not so apt to become dyspeptic while tak- 
ing it. 

The milk of fancy breeds of cows, such as that of thoroughbred 
Alderneys or Durhams, is often too rich both for infants and in- 
valids. 

IV— MIXED FEEDING 

There is no harm whatever in partly feeding infants with the 
bottle who are at the same time being nursed. If the mother is 
suffering from want of sleep she will be of more value to her infant 
if allowed to sleep at night while her child is hand-fed once or twice. 
When the breast milk is insufficient or poor in quality the child must 
be fed by hand several times a day in addition to nursing. A hungry, 
ill-nourished child cries continuously in a fretful manner and nurses 
irregularly, either taking the breast too long and eagerly or stopping 
too soon if it cannot obtain the milk without much effort. The 
sleep is fitful, the abdomen is tender and usually distended with gas. 
There may be vomiting, and the stools are malodorous and contain 
milk curds. Sometimes such babies may be given the bottle for 
the greater part of their food for a few days, until the mother's milk 
is found to agree with them better, and thus the necessity for abso- 
lute weaning may be postponed. 

Infants who are brought up to take the bottle once or twice at 
night, being nursed at the breast in the daytime, are usually more 
easily weaned when the period for entire hand-feeding arrives. 

When a mother who has abundant milk supply is obliged to be 
temporarily absent from her infant beyond the period when a meal 
is due, she may beforehand express into a clean glass a little milk 
which may be kept and fed to the child with a teaspoon while the 
mother is away. 

V— GAVAGE 

When infants have irritable stomachs, gastric catarrh, or when 
they persistently refuse food or are too feeble and marasmic to take 



THE FOOD OF INFANTS 755 

sufficient food, they are fed by the method of " gavage," which con- 
sists in pouring liquid nourishment into the stomach through a 
glass funnel attached to a catheter. A soft-rubber catheter (No. 7) 
may be used. The child is wrapped in a sheet to restrain the arms, 
and then laid on its back upon a table. The catheter is passed 
through the mouth for a distance of about 8 inches, and warm 
milk or broth and, if necessary, medicines may be poured in. 

Weaning 

The period for weaning varies considerably, according to the 
health and vigour of both mother and infant. As a rule, it should 
be between the tenth and eighteenth month, ordinarily not before 
the tenth or twelfth month has been passed. Many infants are 
nursed for fifteen months, but after, if not before the eighteenth 
month the mother's milk deteriorates, and the child's needs will be 
better met by bottle feeding. There can be no fixed rule about this, 
however, and much depends upon the nationality and social position 
of the mother. The poor, for reasons of economy, sometimes nurse 
their children longer than is good for them, and many foreigners in 
this country seem able to nurse their infants longer than native 
Americans. 

The eruption of the eight incisor teeth, which should be com- 
plete by the end of the first year, is often regarded as an indication 
for weaning. At this time the digestive organs become stronger, 
the saliva becomes more abundant, and the appearance of the an- 
terior molar teeth is a sign that the child is gradually preparing 
for solid food. 

Usually, even though the anterior molar teeth are cut, the child, 
if weaned, should still be fed chiefly upon milk until the eighteenth 
month. It is best not to wean a child during very hot weather, but 
when this is imperative milk only should be given, otherwise a small 
quantity of beef juice, egg, etc., may be allowed by degrees. 

An infant may be weaned at any time, and occasion may require 
its being done suddenly, but ordinarily the process should occupy 
at least one or two months. When the child is nine or ten months 
of age the bottle may be given once a day in place of the breast; 
later two or three times, and so on, until at the end of a year the 
weaning is completed. This, however, is a very general rule, sub- 
ject to modifications necessitated by the ill health of mother or 
child, or by hot weather, etc. 

The circumstances which necessitate earlier weaning than the 
period after the twelfth month may be due to the condition of the 
infant, who may have malformation of the mouth or be congenitally 
too feeble to suckle, or rendered so by some disease, such as rickets 
or hereditary syphilis, or the condition of the mother may be at 



756 



RATIONS, DIETARIES 



fault, either from constitutional disease, such as tuberculosis or syph- 
ilis, from local disease, abscess, or malformation of the nipples, from 
insufficient or poor milk, or from the recurrence of menstruation 
or pregnancy. 

If an infant be nursed after the mother's milk has grown poor in 
quality it may acquire rickets and digestive disorders. 

The following directions for weaning an infant from the bottle 
and for feeding during the second year are concisely given by Holt 
in his admirable brochure on The Care and Feeding of Infants. 
They summarise concisely a very large experience : 

" At ten months the bottle or breast milk may be supplemented 
by a little beef juice or a portion of a soft-boiled tgg. If the bottle 
is given, arrowroot or farina may be added to one feeding each 
day. . . . 

" A child should always be weaned as early as eighteen or twenty 
months, but it can be easily done at twelve or fifteen months. . . . 
During the second year a healthy child never requires more than 
five, and some do better with four, meals during the latter half of 
the year. . . . 

" If five meals are given, the best hours are 7 a. m., 10 a. m., 
1 p. m., 4 p. m., 7 p. m., with nothing whatever during the night. It 
is better to make the 10 A. m. and 4 p. m. meals rather smaller than 
the others." 

Starr gives the following mixture in commencing weaning at 
the tenth month : 

Weaning Mixture at Ten Months (Starr) 

Cream , f § ss. 

Milk f I iv. 

Sugar of milk § j. 

Water f § jss. 

If disorder of digestion occurs, return temporarily to the breast. 

Holt presents the following table, based on the measurement of 
forty infant stomachs and the weighing of infants immediately be- 
fore and after nursing. The table gives the averages computed 
from such data, but the robust will require a little more, and the 
feeble will take less food. The measurements are in ounces : 



Age. 


Quantity suckled at one feeding. 


Number of feedings. 


Total daily amount. 


2 weeks 


2 


8 


16 


1 month 


3 


8 


24 


2 months 


4 


7 


28 


4 months 


5 


6 


30 


6 months 


5^-6 


6 


33-36 


9 months 


7-71 


5 


35-38 


12 months 


8-9 


5 


40-45 



THE FOOD OF INFANTS 



757 



After the twelfth month three pints is the limit of digestive 
capacity for food for the stomach for one day. If the child seems 
to need more nourishment, the strength of the food, but not its bulk, 
may be increased. 

Quantity of Food required in the First Year of Infancy (Rotch) 



During the ist week 

At the 3d week 

At the 6th week 

At the 3d month 

At the 4th month 

At the 6th month 

At the 10th or 12th month 



At each feeding. 



2 
3 

4 

6 



Number of daily 
feedings. 



IO 
IO 



Total daily 
amount. 



IO OZ. 

15 " 

16 " 
24 " 
28 " 
30 " 
40 " 



Holt's " Schedule for Feeding an Average Child in Health " for the First 

Year 



Age. 


Number of 
meals. 


Interval by day 
between meals. 


Night feed- 
ings, IO P. M. 
to 6 A. M. 


Quantity for 
each meal. 


Quantity for 
24 hours. 




IO 
IO 

9 

8 

7 
6 
6 

5 
5 


2 hours. 
2 " 
2 " 

2i « 

3 
3 
3 
3 
3 


2 

2 

I 
I 
I 


I OZ. 

ii " 

3 " 

4 " 
5* " 
6 " 

i\ " 

8 " 




2 to 3 weeks 

4 weeks 


15 " 
20 " 


6 " . 


24 " 
28 " 




e " 


33 " 

36 « 

371 " 
40 " 


6 " 


12 " 



Note. — A large child may be given a few ounces more in the 24 hours than the 
quantity above specified, a small child a little less. A large child may pass from one 
formula to the next a little more rapidly than at the time specified, but a small child, 
or one with feeble digestion, will have to proceed more slowly. The hours for feeding 
should in all cases be observed with regularity. 

Chrys tie's Table for Infant Feeding 



Age. 



ist week 

2d to 4th week. . 
2d to 3d month. 
3d to 4th month. 
4th to 5th month 

6th month 

8th month 

10th month 



Interval. 



2 hours. 

2 " 

3 " 

3 " 

3 " 

3 " 

3 " 

3 " 



Number of 
feedings in 
24 hours. 



IO 

9 

6 
6 
6 
6 
6 
5 



Amount of 

food at 

each feeding. 



3 
4 

4-4l 
5 
6 



Total amount 
in 24 hours. 



IO OZ 

131 
18 
24 
24-27 
30 

36 
40 



The foregoing tables differ only in a few unimportant details — 
less, in fact, than the digestive powers of infants differ from each 
other. 



758 



RATIONS, DIETARIES 



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THE FOOD OF INFANTS 759 



Artificial Infant Foods 



Very young infants fed upon " proprietary " or " prepared " baby 
foods, to the greater or less exclusion of mother's or good cow's 
milk, soon become rhachitic or scorbutic. Wiederhofer says that 
" the numerous infant foods, although much bepuffed, are of no 
value whatever." This is certainly true of all non-malted amyla- 
ceous foods. The common fault of nearly all such preparations is 
that they contain too much sugar or starch and too little fat — which 
latter is very difficult to preserve without becoming rancid. For 
example: Prof. Leeds says that Mellin's food has only 0.15 part 
fat in 144.74, and Nestle's food only 1.91 part in 139.69, but human 
milk has 3.90 per cent and cow's has 3.66 per cent. 

Two extreme conditions are seen in such infants — those who are 
emaciated and marasmic, and those who are stout and apparently 
robust, but whose strength and power of resistance to disease is 
very deceptive. As described by Holt : " When children are fed 
upon foods lacking in fat, the teeth come late, the bones are soft, the 
muscles flabby," whereas " children fed upon foods containing too 
much sugar are frequently very fat, but their flesh is very soft, they 
walk late, and they perspire readily about the head and neck." They 
present a variety of rhachitic deformities, and are subject to catarrhal 
and other diseases. Such foods should never be fed to young in- 
fants unless under a physician's direction. For the further discussion 
of this topic the reader is referred to the section upon Prepared 
Farinaceous Foods, p. 148. 

Another objection to feeding infants with starchy food, even 
when partially converted by diastase into dextrin and maltose, is 
that the final products are unlike the carbohydrate of normal milk 
(lactose), and it is doubtful whether they are as readily assimilated 
and as useful in the obscure metabolic processes of infant growth. 

Predigested proteid foods, such as somatose and various forms 
of meat extracts, albumoses, etc., are sometimes used to re-enforce 
the milk of very young infants by addition to it. This is a mistake, 
for the cow's milk is already too rich in proteids. If temporary 
indigestion requires their use, they should be substituted for milk, 
and not given with the idea of re-enforcing it. 

Infant Stools. — The stools of the infant should be observed from 
time to time in order to ascertain whether the milk is being prop- 
erly digested. 

The stools of an infant fed exclusively on milk should number 
two (or only one) a day, and be of uniform soft consistence, smooth, 
of inoffensive odour, and of a gamboge-yellow colour. If meat juice 
or meat broth of any kind is given, the stools usually become darker. 
If too much is given they become acid, malodorous, very dark 
brown, and diarrhceal. 
50 



760 RATIONS, DIETARIES 

Abnormal appearances of the stools will be found described in 
connection with the dietetic treatment of infantile diarrhoea (p. 556). 
When farinaceous or any amylaceous food is being given, it is well 
to test the stools with a few drops of tincture of iodine which im- 
parts a purple colour to any particles of undigested starch which 
they may contain. 

Nursing Bottles. — Ever since the influence of bacteria upon the 
fermentation of milk has been established the necessity for observing 
carefully the most minute details for cleansing all the infant's feeding 
utensils has been apparent. 

The necessity for use of the bottle for feeding is always to be 
regretted on account of the difficulty of keeping the milk from 
bacterial infection. Adams says : " One of the greatest nuisances in 
infantile life is the popular feeding bottle. It probably causes more 
intestinal diseases in the infant under two years of age than any 
other article." 

The use of nursing bottles with long rubber tubing is to be 
unhesitatingly condemned, although it saves trouble in holding the 
bottle. It is impossible to keep the tubing sterile. The bottle 
should be of pure glass, white, of half-pint capacity, with a wide 
mouth and a sloping neck, and never with a shoulder, which pre- 
vents cleaning every part of the interior with a sterilised cotton 
swab. 

A measure of ounces should be blown in the side, and it should 
be fitted with a short black rubber nipple, which can be removed 
and turned inside out for thorough cleansing. This short nipple 
has the further advantage that the child is less apt to be left by 
the nurse alone with the bottle. The latter is a slovenly way to 
feed an infant, and should be discountenanced, for the child gets 
its milk with periods of delay and irregularity. The bottle may slip 
out of reach, or after it is empty the child keeps on sucking or draws 
in air, and obtains the milk at uneven temperatures, or sometimes 
the child goes to sleep with the nipple in its mouth, and, awaking, 
it finishes the bottle. " The sucking power of the child is to a great 
extent produced by the muscles at the posterior portion of the 
mouth ; if this action is carried on to too great an extent it has a ten- 
dency to contract the width of the mouth and cause protrusion of 
the teeth " (Cryer). For these reasons the nurse should always 
continue holding the bottle in a comfortable position for the child 
until it has taken its portion. This usually requires a few minutes 
less time than is occupied in nursing at the breast. The usual time 
is not above ten minutes (Dencke). Any residue in the bottle should 
be at once thrown away, and not warmed over for a second feeding. 

For washing the milk bottles a solution of sodium bicarbonate 
or salicylate, a teaspoonful to the pint, should be first used, after 
which they must be thoroughly scalded in boiling water. If fitted 



FOOD FOR YOUNG CHILDREN 761 

with a plug of sterilised baked absorbent cotton they will remain 
sterile until ready for use. 

When from six to eight teeth have appeared the bottle can usu- 
ally be discarded. 

Care of the Infant's Mouth. — Cryer says that mothers or nurses 
in caring for the infant " will give attention to dirty hands or face 
and bathe the body daily, but how few keep the mouth as clean ! 
The teeth should be gently and thoroughly brushed with a small 
soft tooth brush as soon as they make their appearance. . . . Fer- 
mentation of residual portions of milk remaining in the mouth of 
the infant after feeding is a prolific source of gastric curd, intesti- 
nal irritation, giving rise to colic and diarrhoea. The mouth of the 
child should therefore be kept carefully cleansed, and before each 
feeding be washed out with a solution of boric acid in distilled water 
applied on a soft linen rag." 

Weighing of Infants. — The systematic weighing of infants at 
least once a week is a very useful indication of the progress in 
nutrition and growth which they are making, and it should not be 
neglected. 

Budin reported some interesting experiments with three classes 
of infants — namely, (1) suckled, (2) partly suckled, partly artificially 
fed, (3) artificially fed. During the first fortnight of life he found 
that the gain in weight was considerably more rapid with suckled 
infants, but during the first year of life the infant will gain as much 
weight if fed upon cow's milk as if suckled. Roughly speaking, the 
infant's weight should be doubled in the first five months of life and 
trebled in the first year. 

Premature Infants. — The feeding of premature infants demands 
unusual care. Their bodies are small ; their vitality is low ; their 
digestion is feeble, and their rate of heat loss is rapid. They are 
sometimes advantageously reared in incubators. They are often 
too weak to suckle or even to take the bottle unless they are very 
carefully hand-fed so as to obtain the milk without effort. It may 
be best to feed them by gavage. This method takes less time than 
any other. A small, feeble, puny infant at nine months of age may 
not take as much as ten ounces of milk a day, and yet keep alive. 
Such a baby must be fed at shorter intervals than the rule allows for 
well-developed infants at the same age, and a two-hour interval will 
often be best. Newborn premature infants may at first require feed- 
ing every hour, not over a drachm or two of milk being given at 
a time. 

FOOD FOR YOUNG CHILDREN 

The infant, although weaned, should receive all its food from 
the bottle until at least the twelfth month, and then very gradually 
a few other articles than milk or beef juice may be added. 



762 RATIONS, DIETARIES 

Children often do best, however, upon a milk diet up to the end 
of the second year. 

" Towards the end of the second year all the milk teeth have 
cut through, and the digestive functions have greatly increased in 
power. The lower maxilla becomes stronger, the muscles of masti- 
cation more powerful, the cavity of the mouth larger, the lips more 
fleshy, the oesophagus wider; the salivary glands are better devel- 
oped, and secrete a larger quantity of saliva ; the shape of the stom- 
ach changes, and its walls grow thicker, the intestinal canal longer 
and more capacious ; in short, all the digestive organs are more 
adapted to an animal diet. At this period milk alone could not 
satisfy the child. It may be dispensed morning and evening, but 
during the day more substantial food is of absolute necessity " 
(Ammon). 

Should illness of any kind occur after a child has been put upon 
solid diet, it should at once be given only fluid food again, and this 
does not mean a diet of tea and toast water, but of milk or meat 
broths. 

Servants are often very careless in regard to the food which they 
put within reach of young children, who wish to eat everything 
they see, and ignorant mothers sometimes give children at the 
breast tea, coffee, or beer, and their older children are allowed to 
eat such substances as the skin of potatoes and fruits, sausages, 
or canned corn, with the result of causing acute gastritis or con- 
vulsions. 

On the other hand, children should not be allowed to grow up 
with too little variety in taste. An occasional departure from strict 
rules or a single indulgence in some ordinarily prohibited article 
may do no harm, but serve to gratify and educate the child. 

Young children of four or five years of age or more, commonly 
crave sugar, but do not care for fatty foods. They are apt also to 
like vegetable acids, and are therefore fond of fruits. These acids 
are wholesome, and the fruit is laxative and healthful when ripe and 
fresh. 

It may seem superfluous to separately name the chief prohibited 
substances which must be kept from young children, but experience 
proves the contrary, and when common sense is lacking in those 
who are entrusted with their care, a written list of these foods should 
be given them. If the child's food is too coarse, too much energy 
is diverted in the attempt to digest it, and this is at the expense 
of normal growth and development. Young children should be kept 
out of the pantry and kitchen, where their attention is attracted by 
forms of food which they cannot have. 

It is estimated by Edward Smith that in proportion to its weight, 
the growing child requires about three times as much carbonaceous 
food as the adult and six times as much animal food. 



FOOD FOR YOUNG CHILDREN 763 



Foods Forbidden to all Young Children 

The following articles are particularly indigestible for children, 
and should not be allowed them under four years of age, and some 
of them should not be given at any period of childhood : Fried food 
of all kinds, game, salt food, the flesh of swine in all forms, pickles, 
salads, condiments, except salt, " stews," the " dressing " of fowl, 
sauces, visceral foods (such as liver, kidneys, tripe, etc.), all raw 
vegetables, potatoes (except baked), tomatoes in any form; the 
coarser vegetables, such as beets, turnips, cabbage, etc. ; fancy bread, 
cake, and pastry ; griddle cakes, canned food of all kinds ; fancy con- 
fectionery, sweets, and preserves ; cheese, rich soups, jellies, dried 
or unripe and overripe fruits (bananas, so often given to young 
children, are very bad for them), nuts, fruits with large seeds, such 
as grapes, the skin of all poultry, fruits, or vegetables. 

All food should be plainly and thoroughly cooked. No greasy 
or highly seasoned dishes are permissible, and as a rule twice-cooked 
meats are indigestible. 

Tea, coffee, and alcohol in every form must be withheld. The 
two former beverages interfere with digestion and make the child 
nervous, and the latter lays the foundation for a permanent alcohol 
habit. Soda water with sirups should not be given. Too much 
water should not be allowed with meals, and what is given should 
not be ice cold. 

Children, as they grow up, should continue to observe regularity 
in the hours for taking meals, and the habit of perpetually nibbling 
at cake, crackers, and confectionery between meals should not be 
tolerated. It is best for young children not to be put to sleep 
immediately after their most substantial meal of the day. As they 
require a nap in the early afternoon, many advise giving this meal 
at 4 p. m. 

The following is a useful summary (taken in part from Holt) of 

General Rules for Feeding Young Children 

1. Allow time for meals. 

2. See that the food is thoroughly masticated. 

3. Do not allow nibbling between meals. 

4. Do not tempt the child with the sight of rich and indigestible 
food. 

5. Do not force the child to eat against its will, but examine the 
mouth, which may be sore from erupting teeth ; and examine the 
food, which may not be properly cooked or flavoured. 

If good food is refused from peevishness merely, remove it and 
do not offer it again before the next meal time. 

6. In acute illness reduce and dilute the food at once. 



764 RATIONS, DIETARIES 

7. In very hot weather give about one fourth or one third less 
food, and offer more water. 

The young infant depends wholly upon animal food, and derives 
the necessary carbon largely from the sugar of milk. The older 
child lives in part only upon animal food, and begins to derive addi- 
tional carbon from bread and other cereal foods. 

Quantity of Food Required. — Experiments have been made by 
Ueffelmann, Hasse, and others, to determine the necessary percent- 
age of albuminous food required per diem per kilogramme of body 
weight, by growing children, with the following result : 



Albumin. 



Average weight of child. 



At 2 years 

At 3 to 5 years.. 
At 8 to 11 years. 



4 grammes. 

3-5 

2.5 " 



12.5 kilogrammes. 

15 

24 



Thus it is seen the percentage of albuminous food required di- 
minishes as the child gains in weight, and more carbohydrate food 
is used to replace it. 

The daily average quantity of food required by each child in an 
aggregate of twenty-eight healthy children between the ages of two 
and three years is reported by Starr to be as follows: Bread, 7.5 
ounces; butter, 0.98 ounce; meat (beef), 4.6 ounces; potatoes, 3.9 
ounces ; milk, 32.6 fluid ounces. The daily average for each child 
in an aggregate of twelve children between the ages of three and 
six years was: Milk, 48.6 fluid ounces; beef, 12.1 ounces; rice, 13 
ounces; bread, 10.3 ounces; butter, 1.08 ounce. The daily average 
for each child in an aggregate of twenty-four children between the 
ages of four and ten years was: Roast beef, 12.46 ounces; bread, 
10.23 ounces ; potatoes, 10.03 ounces ; butter, 0.99 ounce ; milk, 38.5 
fluid ounces. 

Dietaries for Young Children 

The following diets are recommended by Starr as types for use 
from the period of weaning up to three and a half years or more : 

Diet from the Twelfth to the Eighteenth Month (Starr) 

7 a. m., stale bread soaked in a breakfast cup of new milk. 

10 a. m., milk, six ounces, and soda biscuit, or a thin slice of 
buttered bread. 

2 p. m., beef tea, six ounces, bread, and a tablespoonful of rice 
and milk pudding. 

6 p. M., same as first meal. 

10 p. m., a tablespoonful of Mellin's food in eight ounces of milk. 

In alternation a lightly boiled egg with bread crumbs and six 
ounces of milk may be given at 7 a. m., and at 2 p. m. a mashed 



FOOD FOR YOUNG CHILDREN 765 

baked potato moistened with four tablespoonfuls of beef tea, two 
tablespoonfuls of junket. 

The following is the sample diet given by Holt for a child eight- 
een months old : 

First Meal. — A tablespoonful of some cereal with salt and one 
tablespoonful of cream, one half pint of milk. 

Second Meal. — One half pint of milk. 

Third Meal. — One tablespoonful of scraped meat, two small 
pieces of dried bread, half a pint of milk. 

Fourth Meal— Milk. 

Fifth Meal — Milk with farina or arrowroot. 

Instead of scraped meat (p. in), beef juice (p. 114) or a soft 
cooked egg may be substituted occasionally. Of the beef juice from 
one to three tablespoonfuls may be given at a time. 

" The quantity of milk allowed at a single feeding for a child 
during the second year should be from eight to ten ounces during 
the first half and from ten to twelve ounces during the latter half 
of the year " (Holt). 

Diet from the Eighteenth to the Thirtieth Month (Starr) 

7 a.m., new milk, eight ounces; the yolk of an egg lightly 
boiled ; two thin slices of bread and butter, or else milk, and two 
tablespoonfuls of well-cooked oatmeal or wheaten grits, with sugar 
and cream. 

1 1 a. m., milk, six ounces, with a soda biscuit or bread and 
butter. 

2 p. m., one tablespoonful of rare mutton pounded to a paste, 
bread and butter, or mashed potatoes moistened with good dish 
gravy, a saucer of junket ; or else a breakfastcupful of beef tea or 
mutton or chicken broth, a thin slice of stale bread, a saucer of rice 
and milk pudding. 

6.30 p. m., a breakfastcupful of milk with bread and butter, or 
soft milk toast. 

Diet from Two and a Half to Three and a Half Years of Age (i. e., for 
Children who have cut their Milk Teeth) (Starr) 

7 a. m., one or two tumblers of milk, a saucer of thoroughly 
cooked oatmeal or wheaten grits, a slice of bread and butter. 

11 a. M. (if hungry), a tumbler of milk or a teacupful of beef tea 
with a biscuit. 

2 p. m., a slice of underdone roast beef or mutton, or a bit of 
roast chicken or turkey, minced as fine as possible, a mashed baked 
potato moistened with dish gravy, a slice of bread and butter, a 
saucer of junket or rice and milk pudding. 

7 p. m., a tumblerful of milk and a slice or two of soft milk toast. 



j66 RATIONS, DIETARIES 

Diet from Three and a Half Years up (Starr) 

Breakfast. — Every day : Milk, porridge and cream, bread and 
butter. 

One dish only each day : Fresh fish, eggs lightly boiled, eggs 
poached, eggs scrambled, eggs (plain omelet), chicken hash, stewed 
kidney, stewed liver. 

Sound fruits may be allowed before and after the meal, according 
to taste, as oranges without pulp, grapes (seeds not to be swal- 
lowed), peaches, thoroughly ripe pears, and cantaloupes. 

Dinner. — Every day : Clear soup, meat roasted or broiled and 
cut into small pieces, bread and butter. 

Two dishes each day : Potatoes baked, potatoes mashed, spinach, 
stewed celery, cauliflower, hominy, macaroni (plain), peas, string 
beans (young), green corn (grated). 

Junket, rice-and-milk or other light pudding, and occasionally 
ice cream, may be allowed for dessert. 

Supper. — Every day : Milk, milk toast or bread and butter, 
stewed fruit. 

From the third to the fifth year the child has twenty teeth, and 
often three meals a day suffice, although from the third to the fourth 
year four may be given. After three years of age it is not possible 
to lay down definite rules for the quantity of food allowed. In 
health, the appetite may be taken as a fair guide, and the child will 
not eat too much if taught to eat very slowly and thoroughly chew 
each mouthful. 

When the second set of teeth begin to replace the deciduous 
or milk teeth, which gradually decay, digestion is sometimes inter- 
fered with temporarily from lack of ability to masticate thor- 
oughly, and food should be subdivided before it is offered to 
the child. 

The following rules for meats and vegetables for young children 
are given by Holt : 

" Meats. — After eighteen months, if most of the teeth are pres- 
ent, once daily, finely bruised or scraped rare roast beef, roast lamb, 
broiled mutton chop or beefsteak, white meat of chicken or turkey, 
fresh fish boiled or broiled — bones the only objection. 

" Vegetables. — Potatoes (not till after second year) roasted, peas, 
asparagus tops, spinach, string beans, boiled onions, stewed celery ; 
all should be very well cooked, in season, and fresh." 

Fruits are very wholesome food for young children from three 
or four years onward, provided they are properly selected and not 
allowed in excess, which is almost the only source of trouble from 
them. They serve to keep the blood in good condition, favor diges- 
tion, and prevent constipation. After the fifteenth month two to 
six teaspoonfuls of orange juice may be given, and a little later the 



FOOD FOR YOUNG CHILDREN j6j 

soft pulp of two or three stewed prunes, or a half-baked or stewed 
apple. 

A child three or four years of age may have a piece of ripe pear, 
peach, or plum, or strawberries in season. Cherries and bananas 
should be forbidden. Grape juice is allowed without the skin or 
seeds. During very hot weather great caution should be observed 
in giving fruit of any kind to infants. 

Bread, rice, oatmeal, and other cereal foods should always enter 
largely into the dietary of healthy children after they are able to 
digest them. Their fats should be derived chiefly from butter and 
cream. The best fruits for them are oranges, cooked apples, and 
stewed prunes. 

Children between three and four years of age should be fed 
when in health four times a day — at 7 a. m., 10.30 a. m., 1.30 p. m., 
and 6 p. m. The following is 

Holfs "Sample Diet for a Child Four Years Old" 

First Meal. — Half an orange, one and a half tablespoonfuls of 
oatmeal or hominy, well salted, with two tablespoonfuls of cream, 
but no sugar, and one glass of milk. 

Second Meal. — A glass of milk or cup of broth and one slice of 
stale bread. 

Third Meal. — Meat — either steak, chop, or chicken — one green 
vegetable (e. g., spinach), one starchy vegetable (e. g., potato), water 
to drink, stewed prunes for dessert. 

Fourth Meal. — Bread and milk or milk toast. 

Desserts for Children 

" After two and a half years — plain custard, ice cream (not oftener 
than once a week), rice pudding (no raisins), baked apple, stewed 
prunes " (Holt). 

The following rules for feeding young children are given by 
Adams : 

When the child has its first sixteen teeth it is to be given more 
varied food than before, such as stale bread and butter, crackers, 
mashed potato and gravy, scraped beef sandwiches with salt or 
sugar, a piece of rare beef, or a chicken bone to suck. He gives 
during the period of sixteen teeth : 

6 a. m., a cup of milk, cream biscuit, or slice of buttered bread; 
8 a. M., stale bread broken and soaked in a tumblerful of rich milk; 
12 m., slice of buttered bread, half a pint of weak beef tea, or mutton 
or chicken broth ; 4 p. M., tumblerful of milk with cracker or a slice 
of buttered bread ; 8 p. m., a tumblerful of milk with bread or 
crackers. 

At the end of the period of sixteen teeth : 



768 RATIONS, DIETARIES 

6 a.m., bread or crackers with half a pint of milk; 8 a.m., a 
tablespoonful of oatmeal, cracked wheat, or cornmeal mush with 
milk and a couple of slices of buttered bread; 12 m., bread and 
butter, milk, and a soft-boiled egg ; 4 p. m., a piece of rare roast 
beef to suck, mashed boiled potatoes, moistened with dish gravy, 
bread and milk, and a small portion of rice, jelly, or farina ; 8 p. m., 
milk and bread or crackers. 

Adams usually prefers, however, to give milk and oatmeal water 
or barley water through the second summer. 

If the child vomits sour food, a little alkali should be added to 
the food (sodium bicarbonate, etc.). Diarrhoea may be excited by a 
too solid diet. 

He prescribes for a child with all the milk teeth, and able to 
walk, up to the third year: 

8 a. m., well-cooked oatmeal, wheaten grits, or cornmeal mush, 
with a liberal supply of milk, cold bread and butter, a piece of finely 
cut, tender beefsteak or a soft-boiled egg] 12 m., bowl of chicken or 
oyster soup, or weak beef tea, milk with bread or crackers, and 
butter; 4 p.m., roast beef, mutton, chicken, or turkey, fresh white 
fish, mashed white potato moistened with gravy, bread and butter, 
and rice and milk ; 8 p. m., milk with bread or crackers. 

Bread and milk or butter may be given between the first and sec- 
ond meal or before the first, also ripe fruit later. 

For a child from the third to the fifth year Adams gives : 

Breakfast. — Cornmeal mush, oatmeal, wheaten grits, hominy, 
plenty of cream ; potatoes, baked or stewed ; eggs, poached, soft- 
boiled, omelet ; fish, fresh broiled ; meats : beef hash, broiled steak, 
stewed liver and kidneys, lamb chops, chicken fricassee ; tomatoes, 
sliced ; bread (cold) ; light Graham, entire wheat, corn muffins 
(plain), and occasionally Graham, corn, and rice cakes ; fresh, ripe 
fruit. 

Luncheon. — Soups: oyster, clam, bean, chicken, consomme; vege- 
tables: potatoes, baked or stewed, sliced tomatoes; beefsteak, lamb 
chop, cold roast lamb ; cold rolls, soda crackers ; fruits in season ; 
rice and milk. 

Dinner. — Soups : consomme, oyster, cream of barley, potato ; 
fish : baked, broiled, or boiled ; roast beef, chicken, lamb ; stewed 
potatoes, rice, cauliflower, macaroni, peas, tomatoes, beans ; bread, 
well-cooked wheat. Dessert : rice and milk, light pudding, ice 
cream, fruits, and berries. 

Teething and Food 

Much illness and digestive disturbance in infancy and early child- 
hood is popularly ascribed to " teething," and the gums do occa- 
sionally become swollen and inflamed during dentition, but the evils 



DIET FOR SCHOOL CHILDREN 769 

of this process are exaggerated in the lay mind and wrong feeding 
is much more often accountable for the disturbance. In regard to 
this matter Adams says, " My experience has taught me that when- 
ever the child has become ill during this physiological process, some 
other cause than the mere cutting of the teeth can be found to 
account for the illness." 

Sleep and Feeding 

The relation of sleep to infant feeding is very well summarised 
by Adams as follows : " A young infant has nothing to do but eat 
and sleep. As soon as he is fed he will take a nap and will prob- 
ably sleep for an hour and a half. After the first year the naps 
become shorter and less frequent. During the second year a nap 
in the morning after breakfast, one in the afternoon about one or two 
o'clock for an hour or an hour and a half are usually sufficient, and 
these naps should be insisted upon for the rest of his mind and body, 
and to enhance his growth and health. As the child attains the 
third year, he can usually drop the morning nap. The afternoon 
one should be insisted upon very soon after the child has its noon- 
day meal, in winter as well as in summer." 



DIET FOR SCHOOL CHILDREN 

Too much attention cannot be given by teachers to the diet of 
the pupils under their care in boarding schools, and they should 
exercise some supervision in regard to the matter in day schools 
as well, for the subject is often ill understood by parents. 

The age for training most school children is from the tenth to 
the seventeenth or eighteenth year. During the entire time both 
mind and body are undergoing development, which in many in- 
stances is exceedingly rapid, and in the midst of this period the 
condition of puberty is attained, which in itself requires additional 
care and watchfulness, especially in girls. 

With the present system of kindergarten training the attendance 
at school of most children begins much younger than the age men- 
tioned. Throughout the whole school period the growth of the 
body is continued until almost completed. The individual organs 
and structures increase in actual size, and there are unusual de- 
mands, therefore, upon the functions of absorption and assimilation. 
The food must be abundant and of the proper character to furnish 
new tissue and to yield energy in the form of heat and muscular 
activity. The former condition is met by a proper allowance of 
animal food in the diet, and the latter by sufficient hydrocarbona- 
ceous material. The food should also contain salts of lime, to meet 
the requirements of formation of the bones and teeth. While the 



7/0 RATIONS, DIETARIES 

material or structural development of the body progresses, there is 
also a marked development in the functions of the various organs ; 
the muscles are trained to act with vigor and with proper co-or- 
dination, and the nervous system is constantly receiving and storing 
new impressions and regulating their transmission and the proper 
relations of inhibitory and reflex actions. The metabolic processes 
of the body are extremely active and the digestive secretions are 
vigorous. To maintain the proper standard, therefore, of growth 
and development requires care in the selection of the right quantity 
and quality of " fuel " or food for the body, and the lack of such 
care too often lays the foundation for future disease, or results in 
an enfeebled constitution with greatly diminished resisting power of 
coping with emergencies which may arise. 

Many children inherit feeble constitutions or diatheses, such as 
the tuberculous, which must be combated throughout the whole 
period of childhood. Such children are better kept at home, where 
they can be under constant observation and proper dietetic treat- 
ment, or country schools can be found for them where such matters 
are made the subject of special consideration. 

Many cases of anaemia and chlorosis, which are so commonly 
seen in young girls during or shortly after the attainment of the 
condition of puberty, are directly traceable to malnutrition from 
faulty diet. Girls take much less exercise than boys, as a rule, and 
are more apt to become constipated. This difficulty may be en- 
hanced by a lack of sufficient fresh vegetables or fruit in their diet, 
and if prolonged it is enough in itself to cause anaemia. The latter 
may also be brought about by insufficient good animal food. It 
should be the imperative duty of every head master of a school for 
children to realise the responsibilities of rightly developing the 
physical constitutions of those entrusted to his care, and to make 
a thorough study of the questions of dietetics involved. He should 
remember that the mind keeps on developing long after the body, 
and that the period under discussion is one in which the constitution 
of the individual is established for the remainder of life, and success 
in digestion and assimilation is of greater importance than success 
in mental attainments. 

Variety. — An important consideration in school diet is to pre- 
vent monotony, which becomes so common from economic reasons, 
or more often from carelessness. It is much easier to yield to 
routine and force of habit or to leave the matter to the indiscre- 
tions of an unintelligent cook. But a little study and thought ex- 
pended upon this subject can always result in furnishing variety in 
a wholesome diet without material increase of expense. 



diet for school children 7/1 

Hours for Meals 

The hours for study and for meals should be so regulated that 
sufficient time should be allowed before each meal for children to 
wash and prepare themselves comfortably without going to the 
table excited by hurry, and they should be required to remain at 
the table throughout a fixed time, never being allowed to hastily 
swallow their food in order to complete an unfinished task or game. 
An interval of half an hour or more should intervene for recreation 
after meals, in order that digestion may be well under way before 
any mental exertion is required. Constant nibbling at food between 
meals should be forbidden ; it destroys the appetite, increases the 
saliva, and interferes with gastric digestion. The number of meals 
for children should be adapted to the age of the pupils. For young 
children from ten to twelve or thirteen years of age it may be neces- 
sary to furnish food somewhat oftener than for older ones. 

If children live at a distance from their school, or if they are 
weak and easily fatigued and inclined to sleep over in the morning, 
their hours for study should be so adjusted that they are never 
obliged to hurry their eating in order to be on time for school work. 
The teachers should consider themselves quite as responsible for 
regulating this matter as are the parents. 

Children should never be hurried oft" to school in the morning 
with an insufficient and rapidly eaten breakfast. Their appetites 
are often poor at this hour from the effects of an ill-ventilated 
sleeping apartment, and if they are subsequently kept at school for 
five hours without luncheon they are very ill prepared for mental 
work. Or they ride to school without exercise after a hasty break- 
fast, take a hurried cold lunch at noon, and perhaps a warmed-over 
late dinner, and at six or seven o'clock a fourth meal, after which 
they are expected to study and go to bed. 

The fact is being more and more realised by teachers and the 
public in general that the breaking down of health at school is 
quite as often, if not oftener, due to impoverished nutrition as to 
overwork. 

A fact which is sometimes overlooked in the dietetic treatment of 
growing children is that their digestive processes are so active that 
the stomach is emptied somewhat sooner than in the case of adults, 
and their meals being' promptly absorbed, it is natural for them to 
become hungry if the intervals between the hours of eating are pro- 
longed. In some schools, children are given their last meal of the 
day at six o'clock in the evening, and they may not breakfast until 
seven or half past seven or even later, leaving an interval of over 
thirteen hours during which they have no food at all. The even- 
ing meal is usually made light, on the ground that they can sleep 
better, and it is, therefore, sooner digested. Robust children can 



7J2 RATIONS, DIETARIES 

perhaps thrive on this treatment, but those less strong are injured 
by it. For some school children of from ten to fourteen years of 
age it will be much better to give the evening meal later, at, say, 
half past seven o'clock, and the breakfast at seven, and if they 
awaken hungry during the night there is no harm in their having 
a glass of milk and a cracker. 

Very delicate children whose appetites are poor and who do not 
do proper justice to their regular meals should be given an extra 
allowance of hot broth or hot milk or an occasional cup of chocolate 
with bread and butter and rusk between meals. 

These general rules are applicable to those children who, 
during one or two years, seem to develop with extraordinary sud- 
denness and rapidity, growing sometimes two inches or more in 
six months and attaining a height quite disproportionate to their 
frames. The demands of this rapid growth must be met by proper 
nutrition or serious subsequent impairment of vitality may result. 
Such children should have their meals made tempting by good cook- 
ing and pleasant variety as well as an agreeable appearance of the 
food. 

Meat which is carved in unsightly masses and vegetables which 
are sodden and tasteless will be refused, and an ill attempt is made 
to supply the deficiency in proper food by eating indigestible candy, 
nuts, etc. Children often have no natural liking for meat, and pre- 
fer puddings, pastry, or sweets when they can obtain them, and it 
is the more important that meat should be made attractive to them 
at the age when they need it. 

It is unnecessary to discuss further questions which after all 
must be controlled by tact and circumstances of individual cases, 
and the line must be drawn with care between making a child too 
fastidious on the one hand in regard to the nature of its food, and 
on the other impairing its constitution by monotony of diet and 
ill-cooked viands. Children at school should be especially required 
to eat slowly, for the habit of fast eating is almost contagious, and 
as it is much easier to acquire than to overcome, the foundation of 
dyspepsia and lifelong discomfort may be laid in this way in child- 
hood. 

A Sample Diet 

If early rising is insisted upon, a child should never be set at any 
task before breakfast, especially in winter, and if it is not expedient 
to serve a full breakfast at half past six or seven the child should be 
given a bowl of hot milk and bread, or a cup of cocoa with a roll, 
or other light food : breakfast may be served later after the first 
exercises of the morning, and should be a substantial meal with 
animal food in the form of either fish, or eggs, or cold meat of some 
sort, with porridge of wheaten grits, or hominy with milk or cream 



DIET FOR SCHOOL CHILDREN 773 

and abundant sugar, also bread and butter, with some sweets in the 
form of jam, or marmalade, or stewed fruit. Dinner, which should 
always be served near the middle of the day, should comprise meat, 
potatoes, with one or two green vegetables, and some form of sweet 
pudding. The supper it is generally admitted should comprise only 
easily digestible articles of food, and such substances as pastry, 
cheese, and meats are better omitted. It should consist of either a 
porridge with milk or cream, or a light farinaceous pudding of rice, 
tapioca, sago, and the like, with bread and butter, and some simple 
form of preserve, or stewed apples or prunes, or very light plain 
cake, or a good bowl of nutritious broth with bread or crackers 
may be substituted for the porridge or pudding. It will sometimes 
be found best to serve this meal at seven o'clock or half past seven, 
and if hungry the child may be given a slice of bread and butter 
and a cup of weak tea or coffee, mostly hot milk, at half past five or 
six o'clock. 

Sample Diet from a Well-known Boys' School in New England 

Breakfast, 7.30 a. m. — Oatmeal. Bread and butter. Stew or 
hashed meat, or beefsteak or chops. Twice a week, griddle cakes 
with sirup. 

Dinner, 1 p. m. — Soup. Fish once or twice a week. Meat, either 
roast beef, beefsteak, mutton, or chicken. Potatoes and green vege- 
tables in season. Pudding, or pie, or plain cake, and lemonade. 
Fruit. 

Supper, 7 p. m. — Cold meat, or hashed meat, or fish balls. Pota- 
toes. Bread and butter. Cake. Preserved fruits. 

Time allowed for Meals. — Breakfast and supper, each half an 
hour ; dinner, three quarters of an hour. Intervals of rest or recre- 
ation for the younger boys (thirteen to fourteen years), after break- 
fast, half an hour ; before dinner, three quarters of an hour ; after 
dinner, two hours and a half ; before and after supper, fifteen minutes. 

On Sundays, breakfast an hour and dinner half an hour later 
than on week-days, and supper five hours after dinner. 

Some of the more important articles of school diet require special 
mention. 

Bread, as a rule, should be made of whole meal, but must not 
be too coarse. The advantage of this bread for children consists in 
its containing a larger proportion of salts, which they need, than is 
found in refined white flour, and butter should be freely served with 
it, to supply the deficiency of fats which exist in wheat. Children 
need fat, but they do not digest meat fat well, as a rule, and are very 
apt to dislike it. They will often take suet pudding, however, when 
hot mutton fat disagrees. 

Milk should be freely supplied not only in the form of puddings 
and porridges, but as an occasional beverage, and children should 



774. RATIONS, DIETARIES 

be made to understand that when hungry they can obtain a glass 
of milk, or a bowl of crackers or bread and milk, for the asking. 

Chambers says : " The best luncheon that a growing young man 
can have is a dish of roast potatoes well buttered and peppered and 
a draught of milk." 

Fresh Fish, eggs, and bacon are all wholesome and serviceable 
foods for children, and 

Meat, as a rule, may be given twice a day, but not oftener. It 
may sometimes be advisable to give it but once a day when fish or 
eggs are supplied ; it should, however, always be given at least once 
daily, and better twice to rapidly growing children. Large, strong 
boys require a great deal of meat, and its use should not be stinted. 
The larger boys may eat from seven to nine or even twelve ounces 
of cooked meat as a ration, although many children may not require 
so much, the smaller boys doing well with from five to six ounces 
and the older boys with from seven to eight ounces daily. 

During midwinter, when fresh vegetables are almost unobtain- 
able in severe climates, vigorous boys sometimes have too much 
meat given them, and Yeo calls attention to the fact that eczema 
may be produced in them by a too exclusive animal diet. 

Sweets. — The greater number of children have a natural craving 
for sweets. The important role of sugars in furnishing energy for 
the body has been discussed (p. 13), and the energy developed in 
active childhood necessitates the consumption of a larger proportion 
of sugar than is required by adults. The craving of children for 
confections, candy, etc., furnishes a true indication of the actual 
requirements of Nature, and it must be admitted that a certain 
amount of wholesome candy, like plain molasses candy, not only 
does most children no harm, but may serve them as an excellent 
food. The main difficulty with such forms of sugar, however, is that 
children are not furnished with a proper porportion of sugar with 
their meals, and the meals themselves are not so regulated as to 
prevent their becoming very hungry between times ; consequently, 
if they can obtain candy, which satisfies them for the time, they 
eat too much, with the result of producing more or less dyspepsia 
and diminishing the normal appetite. If pains be taken to give, 
such children a slice of bread and butter with a little honey or jam 
between meals and a proper proportion of saccharine food with 
their meals, they are much less likely to obtain candy surreptitiously 
and gorge themselves with it. Simple forms of well-cooked pastry 
and of cakes with stoned raisins should be furnished as dessert occa- 
sionally. It is better to give such food from time to time with 
the meals under proper supervision than to have children indulge 
themselves in it. 

Alcohol in every form should be absolutely excluded. If given 
during early youth it is particularly prone to develop a taste which 



DIET FOR SCHOOL CHILDREN 775 

may become uncontrollable in later years. The only exceptions to 
this rule are some sickly and anaemic children who are especially 
under the physician's care. 

Habit. — Many children acquire a habit of dislike or even disgust 
for certain articles of food, which become so fixed in later life that 
they find it very inconvenient, especially when placed in circum- 
stances, as in travelling, where one cannot always obtain the accus- 
tomed diet, and giving in to such habit is often a serious obstacle 
to normal development. There are children who acquire a dislike 
for meat and who persistently refuse to take it, until they become 
anaemic and feeble, and there are others who refuse fresh vegetables, 
which they need. It is a great misfortune for a child to be indulged 
in such likes or dislikes. With a little tact and persuasion the re- 
pugnance can usually be overcome before the habit becomes rooted, 
and these questions are very largely a matter of proper education. 
How often is the physician baffled in the treatment of a severe 
•disease like typhoid fever, which requires the use of a milk diet, by 
the patient's insisting that he has never been able to drink milk 
since childhood ! If there be any taste which is natural to all men 
it is that for milk, upon which all must live during early infancy ; 
and while it is better after a certain period of growth to restrict the 
quantity of milk in the diet, there is no reason at all why children 
should not retain a normal fondness for it. There are, no doubt, 
cases in which it seriously disagrees (see p. J2), but they are ex- 
ceptional as compared with the number of persons who can digest 
milk, when properly prepared, w T ith perfect ease, but whose antipa- 
thy for it prevents them from taking it in the emergencies which 
may befall them in acute disease. 

Children who object to vegetables can sometimes learn to eat 
them when cooked in an unusually attractive manner or served in 
soup. 

Overeating should be guarded against, for habits of gluttony 
may be acquired in youth, especially between puberty and full de- 
velopment, which are never overcome, and which may lead to vis- 
ceral distention and hypertrophy, obesity and other troubles, which 
develop in adult life. The habit of slow eating should be insisted 
upon. 

Exercise. — As a general rule, active muscular exercise in children 
disturbs their digestive processes far less than mental effort when 
taken immediately after meals, and every adult is familiar with the 
romping which children can undertake straightway after dinner, 
often, though not always, with impunity, whereas a proportionate 
amount of exercise on the part of an adult might produce a severe 
dyspeptic attack. It is well to allow children to play but moderately 
immediately after eating, and to require no mental work of them 
at such time. 
51 



77& RATIONS, DIETARIES 

For some reason the diet in girls' schools is often much less 
carefully regulated than in corresponding schools for boys. This 
applies not only in the United States, but it has been found the 
common experience in England and France ; it is the more unfor- 
tunate, since girls from their greater delicacy of constitution, espe- 
cially at the period of puberty, require more careful nurture. Differ- 
ences in habits and exercise and outdoor recreation, no doubt in 
part, are responsible for the comparative lack of proper development 
in some girls' schools as compared with boys', but this should be 
recognised and regulated with as much care as the diet. 

During the establishment of puberty it is best for children to 
avoid stimulating and highly seasoned food, and eating late at night, 
which is apt to excite the sexual organs reflexly and cause lascivi- 
ous dreams. Alcohol should be wholly forbidden. Its use by young 
girls is said to bring menstruation earlier. Some articles of diet 
have a reputed aphrodisiac effect, but this is very slight; such are 
oysters, eggs, peppers, and champagne. 

HOSPITAL DIETARIES 

Statistics of the most economical quantity and quality of food 
for men in health, and under different conditions of activity, have 
been very accurately and practically determined, but such data for 
invalids are in most cases unobtainable, and obviously so, for the 
condition of individual cases and the severity of diseases are con- 
stantly varying, and no definite rules for the exact quantity of food 
needed could be formulated which would be of general application. 
For this reason in many hospitals no attempt is made to classify the 
diet beyond the very elementary subdivisions, consisting, first, of 
milk diet — i. e., milk alone, or of milk with a little bread, and light 
farinaceous food ; secondly, the " full diet," which is commonly 
known either by that name or as " house diet " or " ordinary diet." 
Where no further general classification of the diet is attempted, it is 
customary to have a supplementary list of foods, usually called 
" articles of special diet," from which the visiting physician or sur- 
geon is to select appropriate food for individual cases. The expres- 
sion " low diet," indicating that for the very sick patients, is an 
unfortunate one, as it may have a depressing sound. In other insti- 
tutions, where more care is bestowed upon diet, it is found both 
convenient and practical to subdivide the diet under several addi- 
tional headings; the diet under each heading to contain only spe- 
cially selected and classified foods. This arrangement is to be highly 
commended, as it not only saves much time and confusion, but is 
economical to the institution in preventing waste, instead of sending 
a large number of full diets from the kitchen to the ward, where 
the lighter or more easily digestible articles are selected for the 



HOSPITAL DIETARIES 777 

sicker patients by possibly inexperienced nurses, much of the food 
being returned uneaten. If the diet is assorted in the kitchen and 
sent to the ward in a properly classified condition — that is, so many 
rations of each specified class — there is very much less waste and 
confusion. 

Under this system, the subdivisions which it is found practical 
and advantageous to adopt are the following : 

I. Milk Diet, consisting of from two and a half to three quarts 
of milk per diem, and nothing else. 

II. Convalescent Diet, or half diet, or light diet, as it is variously 
called, intended for patients convalescing from acute disease, or for 
patients who are unable to digest the full house diet. In the average 
medical ward the majority of patients live usually upon this diet, 
which is not adapted for the special requirements of any particular 
disease, but is simply light, nutritious, and easy of digestion, and 
is therefore serviceable in a very large number of cases which do 
not need more careful selection of food. 

III. Farinaceous Diet, from which animal food, with perhaps 
the exception of milk and butter, is excluded. This diet is not of 
very general use, but is temporarily serviceable in some forms of 
disease, such as chronic Bright's disease and acute gout. 

IV. Nitrogenous Diet, or animal food, which is somewhat more 
used than the preceding diet, and from which sugars and almost all 
forms of starchy food excepting a little dried bread, toast, or Graham 
bread, are excluded. This diet is particularly serviceable in cases 
of flatulent dyspepsia, chronic gastric catarrh, and dilatation of the 
stomach, in which the starches and sugars invariably undergo acid 
fermentation, with eructations and flatulence. It also serves for 
diabetics, with slight modification. 

V. House or Full Diet should be the most economical diet for 
the hospital upon which patients who have nearly completed their 
convalescence may be placed, as well as those patients, including 
certain medical cases and a large number of minor surgical cases, 
whose digestive organs are in normal condition. It usually in- 
cludes the coarser articles of food, sometimes corned beef and cab- 
bage, potatoes, codfish, etc., and it is very often the general diet 
for the servants and attendants in hospitals as well as patients. 

VI. Articles of Special Diet. — Under this list are included lux- 
uries and delicacies, such as oysters, jellies, custards, etc., and extra 
allowances of eggs, chicken, cream, and fruits, which may be desir- 
able to furnish in a few individual cases. 

With a system arranged upon this plan, as will be seen by the 
accompanying sample tables, used in some of the representative 
hospitals, the ordering of the diet is simplified for the visiting physi- 
cian or surgeon, and is less likelv to be relegated by him to sub- 
ordinates than it is if he is obliged to spend the time required for 



77% RATIONS, DIETARIES 

selecting a separate menu for each patient in the ward. The limita- 
tions of each separate diet should be distinctly understood by all 
the attendants and nurses, and a printed diet list of articles included 
under the headings " nitrogenous diet," " farinaceous diet," etc., 
should be conspicuously posted in the ward dining or service rooms. 
The daily variations within the limits of these diets should be regu- 
lated by the superintendent of the hospital or an assistant, whose 
special duty it is to provide the food for the institution, and select 
such articles as will give reasonable variety, due allowance being 
made for variations in regard to price and season of the year. 

In many large hospitals not only is the arrangement of the diet 
imperfect, but the details of preparing and serving food are so in- 
efficiently supervised that there is great loss from waste and imper- 
fect cooking, and the additional expense of employing one or two 
specially trained persons to superintend these matters would be 
more than counterbalanced by the saving in the waste and in the 
benefit to the patients. 

Overfeeding. — Too much food is often given hospital patients 
by overzealous nurses, who are anxious to hasten convalescence. 
This is particularly true in the treatment of simple surgical cases 
where there is no special digestive disorder. A man accustomed 
to doing eight hours of active physical labour when put to bed for 
six weeks or more with his leg immobilised for a fracture, does 
not need to be constantly stuffed with large quantities of food, and 
yet such patients, if the matter is not carefully directed, will be often 
found to receive full house diet, which in itself is ample for the 
working attendants of the hospital, and in addition to be given two 
or three quarts of milk a day as a beverage. The natural result is 
constipation, indigestion, with a heavily coated tongue and more or 
less biliousness, which in turn is counteracted by a compound ca- 
thartic pill or a dose of calomel. I have known of night nurses 
going through wards with pitchers of milk, and pouring out tum- 
blerfuls for any patients who were at all thirsty, quite irrespective 
of any supervision. In a large hospital, where the monthly con- 
sumption of milk is from ten thousand to fifteen thousand gal- 
lons, it may be easily seen that its indiscriminate use as a bever- 
age is an item of very considerable and unnecessary expense to 
the institution, besides being an actual detriment to many of the 
patients. 

Another undesirable tendency among American hospital die- 
taries is to include too much meat. The ordinary hospital menu 
compared, for instance, with that of the agricultural labourer, shows 
this fact very strikingly. Not over four ounces of cooked meat 
(without bone) need be allowed in the meal for men. 

Fish Diet. — In some hospitals in addition to the subdivisions 
of the diet above given, a " fish diet " may be ordered, which is 



HOSPITAL DIETARIES 779 

very useful and should be generally adopted. In the London Fever 
Hospital this diet consists of a ration of bread ten ounces and fish 
eight ounces (the uncooked measure), such as haddock, cod, or sole, 
or some similar fish, potatoes eight ounces, cocoa one ounce, with 
half an ounce of sugar and a sixth of a pint of milk. This is a 
serviceable and economical form of diet for a considerable class of 
patients for whom large quantities of meat are not only unnecessary 
but injurious. 

Broth Diet. — In children's hospitals a diet is sometimes classified 
as the " broth diet," i. e., mutton broth flavoured with vegetables, 
and bread and butter, with milk ; or a " beef-tea diet," in which the 
beef tea replaces the broth ; and in the lighter diet of children, 
gruels, bread and molasses, and simple articles of farinaceous food 
such as farina, cornstarch, rice, etc., should play an important role. 
Sometimes such diet goes under the name of " soft food." 

In some of the English hospitals, as in the London Fever Hos- 
pital, beer is allowed with the full diet, and in this hospital also a 
discrimination is made in ordering the diet according to sex, females 
being given from two to four ounces less bread and two to three 
ounces less meat than males. This discrimination is not usually 
made in American hospitals. 

Sample Hospital Dietaries 
dietary of the new york hospital 

" All patients shall be furnished the regular house diet, unless 
otherwise specially directed by the attending physician or surgeon. 
As a substitute for the house diet, there may be furnished, on the 
order of the attending physician or surgeon only, either of the fol- 
lowing : 

" i. Restricted diet. 

" 2. Milk diet. 

" The attending physician or surgeon shall specify, on the occa- 
sion of his first visit to a patient, which diet shall be furnished. 
This duty may not be delegated to the house physician or house 
surgeon, except that, on the admission of a patient to a ward, 
it shall be the duty of either to give instruction on the subject to 
the nurse in charge, and such instruction shall be followed until 
the first visit of the attending physician or surgeon. 

" The wards shall be supplied with blanks, called diet lists. The 
head nurse shall carry one of these with her regularly when accom- 
panying the attending physician or surgeon on his visits, and shall 
note down carefully all his instructions as to diet ; he shall sign 
these lists before leaving the ward. 

" Milk diet, or restricted diet, may not be ordered in addition 
to the regular house diet, but only as a substitute therefor, but the 



780 RATIONS, DIETARIES 

attending physician or surgeon may order items of special diet in 
particular cases. 

" Lists denning the different classes of diet shall be furnished 
each attending physician and surgeon. 

" Cards, appropriately inscribed, shall be placed at the head of 
each bed, which shall designate the class of diet, and also the amount 
of stimulant, which is furnished each patient. 

" A diet kitchen is established, under the direction and control 
of the directress of nurses, wherein articles of special diet shall be 
prepared and served as ordered. 

" Daily House Diet 

''Breakfast. — Oatmeal or hominy; tea or coffee, with milk and 
sugar ; bread and butter. 

"Dinner. — Potatoes; bread and butter; one or more of the fol- 
lowing vegetables : turnips, sweet potatoes, beets, spinach, squash. 

" Supper. — Tea with milk and sugar ; bread and butter ; stewed 
or fresh fruit. 

"In addition on Sunday. — Breakfast: eggs. Dinner: roast beef, 
cornstarch pudding. Monday. — Breakfast : baked potatoes. Din- 
ner : stock soup, stewed beef or mutton, rice pudding. Tuesday. — 
Breakfast : mutton chops. Dinner : pea soup, roast mutton, bread 
pudding. Wednesday. — Breakfast : fried or stewed potatoes. Din- 
ner : roast beef, cornstarch pudding. Thursday. — Breakfast : eggs. 
Dinner : stock soup, stewed beef or mutton, tapioca pudding. Fri- 
day. — Breakfast : salt mackerel or codfish. Dinner : bean soup, 
baked fish, beans, rice pudding. Saturday. — Breakfast : beefsteak, 
Dinner : corned beef, cabbage, bread pudding. 

" Restricted Diet 

" Breakfast. — Tea or coffee (with milk and sugar), farinaceous 
food (with milk), eggs. 

" Dinner. — Soup ; either of the following: raw oysters, roast beef, 
steak, chicken with vegetables, pudding (bread, rice, tapioca, or corn- 
starch). 

" Supper. — Tea (with milk and sugar), bread (with butter), fruit 
(fresh or dried). 

" Milk Diet 

" Six pints of milk daily. • 

" Articles of Special Diet 

" Milk, eggs, beef tea, oysters, cornstarch, chops, steak, chicken, 
chicken soup, rice, broth, farina, ice cream, as ordered by the attend- 
ing physician or surgeon. 

" Salt fish, jellies, custards, gruels." 



HOSPITAL DIETARIES 78 I 

At the New York Hospital a carefully graduated diet list, made 
out in ounces per capita, was formerly in use, but it was found both 
unnecessary and unpractical. Separate tables are laid for the pa- 
tients, nurses, and servants ; but the amount of food is estimated 
in a general way, the terms being based rather upon the cost price 
per capita than upon the number of ounces, and it is proportioned 
by the housekeeper and her assistants with due regard to economy. 

DIETARY OF THE PRESBYTERIAN HOSPITAL, NEW YORK, 1901 

Although the diet is very satisfactory and ample at the Presby- 
terian Hospital, New York, the food allowance per capita for patients 
is not separately estimated, and the house diet, convalescent diet, 
and diet for the servants on pages 782-783 are all originally pre- 
pared in bulk, and subsequently subdivided by the cooks and nurses 
under the order of the visiting physicians and surgeons, but without 
regard as to accurate measurement of quantity in ounces. 

The diet sheet on page 784 is in daily use in the wards at the 
Presbyterian Hospital, New York city. It will be observed that 
it is properly classified according to quality as well as quantity. It 
was introduced several years ago after a careful comparison with 
diets of other institutions, and it has proved very practical. It is 
the most liberal and best-classified diet of any hospital with which 
I am familiar. 

DIETARY IN BELLEVUE, GOUVERNEUR, FORDHAM, AND 
HARLEM HOSPITALS, NEW YORK, 1901 

Monday 

Breakfast. — Coffee, one pint, with half an ounce of milk and half 
an ounce of sugar ; bread, five and one third ounces, and a quarter 
of an ; ounce of butter; oatmeal, one ounce; crackers, one ounce; 
milk, one quart. 

Dinner. — Roast beef, eight ounces; rice, one ounce; soup, one 
pint ; potatoes, eight ounces ; vegetables, four ounces ; bread. 

Supper. — Tea, one pint, with half an ounce of milk and half an 
ounce of sugar ; five and one third ounces of bread and a quarter 
of an ounce of butter ; one ounce of stewed apples. 

Tuesday 

Breakfast. — Coffee, one pint, with half an ounce of milk and half 
an ounce of sugar ; bread, five and one third ounces, and a quarter 
of an ounce of butter ; hominy, one ounce ; crackers, one ounce ; 
milk, one quart. 

Dinner. — Mutton stew, eight ounces ; potatoes, eight ounces ; 
vegetables, four ounces ; bread, five and one third ounces ; bread 
pudding, two and a half ounces. 



782 



RATIONS, DIETARIES 



House Diet. 


Convalescent Diet. 


Nitrogenous Diet. 


BREAKFAST. 


BREAKFAST. 


BREAKFAST. 


Tea or coffee (milk and 


Tea or coffee (milk and 


Tea or coffee (milk 


sugar). 


sugar). 


Bread and butter — 


Bread and butter — 


Bread and butter — 


Graham bread. 


White bread, or 


White bread, or 




Graham bread, or 


Graham bread, or 




Corn bread, or 


Corn bread, or 




Rolls, or Toast. 


Rolls, or Toasl. 




Porridge — 


Porridge — 




Oatmeal, or 


Hominy, or 




Wheaten grits, or 


Farina. 




Indian meal, or 






Hominy, or 






Farina, or Samp. 






Meats — 


Meats — 


Meats — 


Hash, or 


Eggs, or 


Eggs, or 


Eggs, or 


Fresh fish, or 


Fresh fish, or 


Salt fish, or 


Stew (plain). 


Stew without vegeta- 


Fresh fish, or 




bles, or 


Stew. 




Meat hash without po- 
tatoes. 


DINNER. 


DINNER. 


DINNER. 


Soup — 


Soup — 


Soup- 


Stock, or 


Stock, or 


Stock, or 


Mutton broth, with bar- 


Chicken, or 


Chowder. 


ley or vegetable, or 


Mutton broth, with bar- 




Chowder. 


ley or vegetable. 




Dry bread. 


Dry bread. 


Graham bread. 


Meats — 


Meats- 


Meats — 


Beef (roast or boiled), or 


Beef (roast or boiled), or 


Beef (roast or boiled), or 


Mutton (roast or boiled), or 


Chicken, or 


Mutton(roast or boiled),or 


Corned beef, or 


Fish (fresh). 


Fresh fish, or 


Fresh fish, or 




Irish stew. 


Irish stew. 






Vegetables — 


Vegetables — 


Vegetables — 


Potatoes, baked, boiled, 


Potatoes (baked), or 


Spinach, or 


or mashed, and 


Rice, or 


Lettuce, or 


Tomatoes, or 


Macaroni, or 


Celery, or 


Baked beans, or 


Samp. 


String beans. 


French beans, or 






Turnips, or 






Beets, or 






Rice, or 






Macaroni, or Samp. 






Pudding — 


Pudding — 


Pudding — 


Rice, or 


Rice or 


Custard. 


Bread, or 


Bread, or 




Tapioca, or 


Tapioca, or 




Farina, or 


Farina, or 




Corn starch, or Custard. 


Corn starch, or Custard. 




SUPPER. 


SUPPER. 


SUPPER. 


Tea (sugar and milk). 


Tea (milk and sugar). 


Tea (milk). 


Bread and butter, or 


Bread and milk, or 


Graham bread and but- 


Toast and butter. 


Milk toast, or 


ter, or 




Bread and butter, or 


Bread and milk. 




Toast and butter. 


Eggs, or 


Fruit — 


Fruit — 


Cold meat. 


Apples, stewed or baked, or 


Apples, stewed or baked, or 




Prunes, or Pears. 


Prunes, or Pears. 





HOSPITAL DIETARIES 



783 



Farinaceous Diet. 


Milk Diet. 


Extras. 


BREAKFAST. 


BREAKFAST. 


ORDERED ONLY BY THE 


Tea or coffee (milk and 


One quart of milk. 


ATTENDING PHYSICIAN 


sugar). 




OR SURGEON. 


Bread and butter — 




Mutton chops. 


White bread, or 




Beefsteak. 


Graham bread, or 




Scraped beef. 


Corn bread, or 




Beef tea (made with hy- 


Rolls, or 




drochloric acid). 


Toast. 




Chicken (broiled, fricas- 


Porridge — ■ 




seed, or roast). 


Hominy, or 




Chicken broth. 


Farina, or 




Eggs- 


Indian meal. 




Milk. 
Oysters. 
Clam broth. 
Gruels. 
Crackers. 
Gingerbread. 
Custard. 
Milk toast. 


DINNER. 


DINNER. 




Soup — 


One quart of milk. 




Vegetable, or 






Macaroni, or 






Barley broth. 






Dry bread. 






Vegetables — 






Baked potatoes and 






Tomatoes, or 






French beans, or 






Rice, or 






Macaroni, or 






Samp. 






Pudding — 






Rice, or 






Bread, or 






Tapioca, or 






Farina, or 






Cornstarch. 






SUPPER. 


SUPPER. 




Tea (milk and sugar). 


One quart of milk. 




Bread and milk, or 






Milk toast, or 






Hominy, or 






Boiled rice, or Farina. 






Fruit — 






Apples stewed or baked, or 




' 


Prunes, or Pears. 







7 8 4 



RATIONS, DIETARIES 



































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HOSPITAL DIETARIES 785 

Supper. — Tea, one pint, with half an ounce of milk and half an 
ounce of sugar ; bread, five and one third ounces ; butter, a quarter 
of an ounce. 

Wednesday 

Breakfast. — Coffee, one pint, with half an ounce of milk and half 
an ounce of sugar ; five and one third ounces of bread and a quarter 
of an ounce of butter ; rice, one ounce ; crackers, one ounce ; milk, 
one quart. 

Dinner. — Roast beef, eight ounces; barley soup, one pint; pota- 
toes, eight ounces ; bread, five and one third ounces. 

Supper. — Tea, one pint, with half an ounce of milk and half an 
ounce of sugar; bread, five and one third ounces, and a quarter of 
an ounce of butter; stewed prunes, one ounce. 

Thursday 

Breakfast. — Coffee, one pint, with half a pint of milk and half an 
ounce of sugar ; five and one third ounces of bread and a quarter of 
an ounce of butter ; oatmeal, one ounce ; crackers, one ounce ; milk, 
one quart. 

Dinner. — Beef stew, eight ounces ; potatoes, eight ounces ; vege- 
tables, four ounces ; bread, five and one third ounces. 

Supper. — Tea, one pint, with half a pint of milk and half an ounce 
of sugar ; five and one third ounces of bread and a quarter of an 
ounce of butter ; one ounce of stewed apples. 

Friday 

Breakfast. — Coffee, one pint, with half an ounce of milk and half 
an ounce of sugar ; five and one third ounces of bread and a quarter 
of an ounce of butter ; two eggs ; crackers, one ounce ; milk, one 
quart. 

Dinner. — Baked fish, eight ounces ; potatoes, eight ounces ; vege- 
tables, four ounces; bread, five and one third ounces; rice pudding, 
two and a half ounces. 

Supper. — Tea, one pint, with half a pint of milk and half an ounce 
of sugar : five and one third ounces of bread and a quarter of an 
ounce of butter. 

Saturday 

Breakfast. — Coffee, one pint, with a quarter of a pint of milk and 
a quarter of an ounce of sugar ; five and one third ounces of bread 
and a quarter of an ounce of butter ; hominy, one ounce ; crackers, 
one ounce ; milk, one quart. 

Dinner. — Mutton stew, eight ounces ; potatoes, nine ounces ; 
vegetables, four ounces ; bread, five and one third ounces. 



786 RATIONS, DIETARIES 

Supper. — Tea, one pint, with milk half a pint, and half an ounce 
of sugar; bread, five and one third ounces; butter, a quarter of an 
ounce ; stewed prunes, one ounce. 

Sunday 

Breakfast. — Coffee, one pint, with half a pint of milk and half an 
ounce of sugar ; five and one third ounces of bread and a quarter of 
an ounce of butter ; crackers, one ounce ; milk, one quart ; two eggs. 

Dinner. — Corned beef, eight ounces; bean soup, one pint; pota- 
toes, eight ounces ; bread, five and one third ounces ; cornstarch 
pudding, two and a half ounces. 

Supper. — Tea, one pint, with half a pint of milk and half an ounce 
of sugar; bread, five and one third ounces, and butter, a quarter of 
an ounce. 

Milk Diet 

To be prescribed by attending physicians or surgeons. 

Articles of Special Diet 
Beefsteak, half a pound ; beef tea, one pint ; chicken, half a 
pound ; chicken soup, one pint ; rice and milk, one pint ; two eggs ; 
milk, one quart. 

DIETARY OF THE ROOSEVELT HOSPITAL, NEW YORK 

The ward diet of the Roosevelt Hospital, New York city, is 
classified as follows : 

Full Diet 

Daily. — Meat, dressed, eight ounces ; potatoes, eight ounces ; 
bread, twelve ounces ; butter, one ounce ; sugar, two ounces and a 
half ; milk, half a pint ; coffee, half an ounce ; tea, an eighth of an 
ounce. On Sundays, Tuesdays, and Thursdays, other vegetables in 
addition to potatoes, two ounces ; bread, rice, or tapioca pudding. 
On Mondays and Wednesdays, soup, one pint. On Fridays, fish. 

Breakfast. — Coffee with sugar and milk, bread and butter, por- 
ridge of oatmeal, wheaten grits, or samp. 

Dinner. — Sunday : Roast beef, potatoes, tomatoes, or other vege- 
table, bread, and bread pudding. Monday : Soup, boiled mutton, 
potatoes, and bread. Tuesday : Corned beef, twelve ounces ; cab- 
bage or turnips, potatoes, and bread. Wednesday : Soup, roast beef r 
potatoes, and bread. Thursday : Soup, boiled beef, potatoes, onions, 
tapioca, sago, or farina pudding, and bread. Friday : Fish, boiled 
or roast beef, potatoes, bread, boiled rice sweetened with sugar and 
milk, and raisins. Saturday : Stew of mutton, potatoes, and bread. 

Supper. — Tea with sugar and milk, bread and butter, baked 
apples, or stewed pears, or prunes, or green or dried apple sauce, and, 
on Sundays, gingerbread varied, alternate weeks, with currant buns. 



HOSPITAL DIETARIES 



78/ 



Half Diet 
Daily. — Meat, dressed, four ounces ; potatoes, four ounces ; bread, 
six ounces ; of other articles, the same as in full diet. 

Milk Diet 
Daily. — Milk, two pints; bread, twelve ounces; rice or samp, 
two ounces ; butter, one ounce. 

Extras 
In addition to the above, the following extras may be ordered 
by the visiting physicians and surgeons : Beefsteak, chicken soup, 
gruel, beef tea, oysters or clams, cornstarch, mutton chops, milk, 
rice, chicken, eggs. 

DIETARY OF THE JOHNS HOPKINS HOSPITAL, BALTIMORE 

At the Johns Hopkins Hospital the Free Ward Diet is liberal, 
but no attempt is made to classify the food qualitatively as served 
to the wards. A sample Sunday menu given there is the following. 
It is expensive, owing to the excess of animal food : 

Breakfast. — Corned-beef hash, oatmeal, toast, eggs, bread and 
butter, coffee or tea, and milk. 

Dinner. — Soup, roast beef, potatoes, rice, turnips, toast, pud- 
ding and milk, bread and butter. 

Supper. — Cold roast beef or pressed corned beef, bread and but- 
ter, coffee or tea, and milk. 



DIETARY FOR LIVERPOOL INFIRMARY 

Sample Diet suggested for the Liverpool Infirmary and other English 

Hospitals 





Sick. 


Normal. 


Convalescence. 


Breakfast, 
8.30 A. M. 


\ pt. milk. 

3 oz. bread or oatmeal. 


f pt. of new milk. 
6 oz. bread. 
2 oz oatmeal. 


1 pt. new milk. 
8 oz. bread. 
3 oz. oatmeal. 




If cocoa or coffee is given with sugar, omit the oatmeal and give \ pt. 
of milk. 


Dinner, 
1 . 30 P. M. 


\ pt. of milk, made into 
pudding with rice, sago, 
etc. 

\ pt. beef tea. 

4 oz. bread. 


Meat, 4 oz. (men). 

" 3 oz. (women). 
Bread, 6 oz. 
Potato, 8 oz. 
Cheese, \ oz. 


Meat, 4 oz. 
" 3 oz. 
Bread, 8 oz. 
Potato, 8 oz. 
Cheese, 1 oz. 




Same for all as the breakfast, but with addition of a cereal. 


Supper, 
6.30 to 7 P.M. 




f pt. broth with boiled 

meat. 
Salt ad libitum. 




Bed at 8 P. M. 


Malt liquor as exceptional treat. 

1 Total bread, 18 oz. 


Total bread, 
24 oz. 



788 RATIONS, DIETARIES 



DIETARY OF THE COOK COUNTY HOSPITAL, CHICAGO 

In the Cook County Hospital, of Chicago, the official diets are 
f our — y\z., ward diet, light diet, special diet, milk diet. 

Extras may be ordered, such as chickens, chops, beefsteak, eggs, 
cream, crackers, lemons, or additional butter, milk, sugar, sirup, and 
vinegar. 

Here again no special attempt is made to classify foods quali- 
tatively. 

The following is a sample midsummer diet, from a smaller hos- 
pital, having about seventy beds, in which attention is economically 
given to variety in food cookery which would be impossible in a 
larger institution without incurring needless expense : 

WARD DIETARY OF THE NEW YORK INFIRMARY FOR WOMEN 
AND CHILDREN, 1901 

Sunday 

Breakfast. — Full Diets : Hominy with milk, fish balls or creamed 
fish, brown bread or biscuit, coffee with milk and sugar, fresh fruit. 
Half Diets : Hominy with milk, toast, coffee, fresh fruit. 

Dinner.— -Full Diets : Soup, bread, roast beef, sweet or white 
potatoes, spinach or tgg plant, pudding. Half Diets : Clam broth, 
toast, chicken or beef jelly, rice, or ice cream. 

Supper. — Full Diets : Pressed beef or cream salmon, bread and 
butter, cocoa. Half Diets : Indian meal porridge and milk, toast, 
cocoa, fruit. 

Monday 

Breakfast. — Full Diets : Oatmeal and milk, bread and butter, 
poached eggs on toast, coffee with milk and sugar. Half Diets : 
Oatmeal, eggs on toast, coffee, fresh fruit. 

Dinner. — Full Diets : Soup, bread, roast lamb, spaghetti, toma- 
toes or lima beans, rice pudding or prune pudding or cottage pud- 
ding. Half Diets : Chicken broth, toast, spaghetti, rice pudding or 
cottage pudding. 

Supper. — Full Diets : Baked potatoes and bacon or creamed beef 
or toast, bread and butter, tea, fruit. Half Diets : Hominy and milk, 
bread and butter or toast, tea, fruit. 

Tuesday 

Breakfast. — Full Diets : Wheat flakes and milk, beef mince or 
hash, bread and butter, coffee. Half Diets : Wheat flakes, buttered 
toast, coffee, fresh fruit. 

Dinner. — Full Diets : Soup, bread, steak, cresses, potatoes, beans 
or carrots or beets, boiled or baked custard or ice cream. Half 
Diets : Mutton broth, rice, toast, custard or ice cream. 



HOSPITAL DIETARIES 789 

Supper. — Full Diets : Brown bread and butter, cream cheese or 
boiled eggs or sliced beef, fruit, cocoa. Half Diets : Oatmeal jelly 
and milk, toast, fruit, cocoa. 

Wednesday 

Breakfast. — Full Diets : Hominy with milk, lamb mince or lamb 
with cream sauce, bread, butter, coffee. Half Diets : Hominy with 
milk, buttered toast, boiled eggs, coffee, fresh fruit. 

Dinner. — Full Diets : Soup, bread, chicken, potatoes or rice, peas, 
tapioca or fruit pudding or custard. Half Diets : Broth, rice, toast, 
tapioca. 

Supper. — Full Diets : Spaghetti and tomato or sliced tomatoes or 
baked corn, bread and butter, tea, fruit. Half Diets : Wheat flakes 
and milk, toast, tea, fruit. 

Thursday 

Breakfast. — Full Diets : Oatmeal and milk, fresh fish, bread and 
butter, coffee. Half Diets : Oatmeal and milk, toast, coffee, fresh 
fruit. 

Dinner. — Full Diets: Soup, bread, braised beef, macaroni, spin- 
ach or string beans, wine jelly or fruit jelly. Half Diets : Chicken 
broth, macaroni, toast, wine jelly. 

Supper. — Full Diets : Beef stew or cream toast or pea soup, bread 
and butter, cake, fruit, cocoa. Half Diets : Cream toast, cocoa, fruit. 

Friday 

Breakfast. — Full Diets : Wheat flakes and milk, scrambled eggs 
on toast, bread and butter. Half Diets : Wheat flakes and milk, 
eggs, toast, coffee, fresh fruit. 

Dinner. — Full Diets : Soup, bread, fish, potatoes, tomatoes or 
peas, bread pudding or Indian pudding or ice cream. Half Diets : 
Lamb broth, rice, bread pudding or ice cream. 

Supper. — Full Diets : Chowder or boiled eggs, bread and butter, 
tea, fruit. Half Diets : Oatmeal jelly, toast, tea, fruit. 

Saturday 

Breakfast. — Full Diets : Indian meal porridge and maple sirup 
or milk, beef ragout, bread and butter, coffee. Half Diets : Indian 
porridge, toast, coffee. 

Dinner. — Full Diets : Soup, bread, steak, potatoes, cauliflower or 
squash. Half Diets : Chicken broth, toast, rice, rennet custard, blanc 
mange. 

Supper. — Full Diets : Lamb stew or baked beans, bread and but- 
ter, tea, fruit. Half Diets : Wheat flakes and milk, toast, tea, fruit. 

Food which may be ordered by resident or attending physicians 
when daily diet is not adequate or suitable : 

Beefsteak, chops, chicken, beef jelly, chicken jelly, scraped beef 



790 RATIONS, DIETARIES 

balls, raw beef sandwiches, clam broth, crackers, extra eggs and 
milk, gruels, oatmeal jelly, wine or fruit jelly, cold beef extract 
made with hydrochloric acid. 

Average Daily Dietary for Adult Women Patients, iqoi, not including 
Milk, Eggs, or Beef Tea for Special Cases 

Flour, meal, rice, or beans, uncooked \ ounce. 

Bread 8 ounces. 

Butter and fat i\ " 

Sugar. 2 " 

Breakfast cereals, uncooked I ounce. 

Meat or fish, dressed but uncooked 8 ounces. 

Potatoes, dressed but uncooked 5 to 6 

Fresh or canned vegetables, cooked 4 to 5 

Stewed or fresh fruit, prepared or cooked 3 to 4 

Soup & pint or 8 

Milk 1 " " 16 

Coffee £. " " 8 

Tea or cocoa \ " " 8 

Eggs, one every other day \ ounce. 

NEW YORK STATE HOSPITAL— PROPOSED DIETARY 

Austin Flint recommends the following dietary and food supply 
for the New York State Hospital : 

" The table is intended for patients not upon extra diet and 
attendants only, and I have suggested that 25 per cent in the rations 
of meat, flour, and potatoes be added for workers." 

Daily Ration 

Meat, with bone, including salted meats, fresh and salted 

fish, and poultry 12 ounces. 

Flour, to be used in making bread and in cooking (may in 

part be substituted by cornmeal and macaroni) 12 " 

Potatoes 12 " 

Milk 16 " 

One egg 2 " 

Sugar 2 " 

Butter 2 

Cheese 1 ounce. 

Rice, hominy, or oatmeal \\ " 

Beans or peas (dried). i£ " 

Coffee (in the berry and roasted) % " 

Tea(black) \ " 

Supplies for One Hundred Persons for Thirty Days 

Meat, with bone, including salted meat, fresh and salted 

fish, and poultry, total 2,250 pounds. 

Flour (may be in part substituted by cornmeal and macaroni) 2,250 " 

Potatoes 2,250 " 

Milk 1,500 quarts. 

Eggs . 250 dozen. 

Sugar 490 pounds. 

Butter 430 

Cheese 215 " 

Rice 108 

Hominy 108 " 

Oatmeal 108 " 

Coffee 180 

Tea 26 " 



HOSPITAL DIETARIES 791 

" Flour should be interchangeable, on this basis, with potatoes, 
rice, hominy, and oatmeal. Butter and cheese may be interchange- 
able in the proportion of one pound of butter to two pounds of 
cheese; and eggs and milk, in the proportion of two eggs to one 
pint of milk. There are occasions when eggs may be substituted 
with advantage for meat. This may be done on the basis of eight 
eggs for one pound of meat. When fruits, fresh and dried, are used 
in abundance, a reduction may be made in eggs, butter, cheese, and 
milk." 

DIETARY OF THE UTICA STATE HOSPITAL FOR THE INSANE 

Monday 
Breakfast. — Cold corned beef, oatmeal, boiled potatoes, bread 
and butter, tea or coffee. 

Dinner. — Roast beef, boiled potatoes, gravy, boiled rice, bread 
and butter, tea. 

Supper. — Roll, bread, sirup, butter, tea. 

Tuesday 

Breakfast. — Cold roast beef, oatmeal, boiled potatoes, bread and 
butter, tea or coffee. 

Dinner. — Vegetable soup, boiled mutton, boiled potatoes, bread 
and butter, and tea. 

Supper. — Molasses cookies, bread and butter, tea. 

Wednesday 

Breakfast. — Roast mutton, oatmeal, boiled potatoes, bread and 
butter, tea or coffee. 

Dinner. — Roast veal, boiled potatoes, Indian pudding, gravy, 
bread and butter, tea. 

Slipper. — Stewed prunes, bread and butter, tea. 

Thursday 

Breakfast. — Cold roast veal, oatmeal, boiled potatoes, bread and 
butter, tea or coffee. 

Dinner. — Baked salt pork, baked beans, boiled potatoes, bread 
and butter, tea. 

Supper. — Cheese, roll, bread, sirup, butter, tea. 

Friday 
Breakfast. — Codfish, oatmeal, boiled potatoes, bread and butter, 
tea or coffee. 

Dinner. — Fresh fish, boiled potatoes, dried raspberry pie, bread 
and butter, tea. 

Supper. — Sugar cookies, bread and butter, tea. 
52 



792 RATIONS, DIETARIES 

Saturday 

Breakfast. — Cold roast beef, oatmeal, boiled potatoes, bread and 
butter, tea or coffee. 

Dinner. — Corned beef, boiled cabbage, boiled potatoes, bread 
and butter, tea. 

Supper. — Corn and wheat bread, cheese, butter, tea. 

Sunday 

Breakfast. — Boiled eggs, oatmeal, boiled potatoes, bread and 
butter, tea or coffee. 

Dinner. — Cold boiled ham, boiled potatoes, pickled beets, canned 
corn, bread and butter, tea. 

Supper. — Ginger cookies, bread and butter, tea. 

Fresh vegetables and fruits in their season. 

Extra diet may be ordered as follows : Milk toast, dry toast, egg 
on toast, beef tea, beefsteak, chops, ham, scrambled eggs, fried and 
boiled eggs, baked custard, cornstarch, rice and milk, gruel, sauce,, 
hot milk, and chocolate. For each patient the daily allowance is : 

Butter . . i-i- oz. 

Sugar ii " 

Potatoes 1 1 5 " 

Coffee f - " 

Tea \ " 

Flour ir \ " 

Fresh beef 10 " 

Fresh vegetables in season and in varying amount. 

Extra Diet 

f Milk toast (for breakfast) ) _. 
I n c /^ i -i , x r 1 hree times a day. 

! Beef tea (Cybils's extract) j 3 

Acute mania. i Grud ^ njght) 

[ Milk (about three quarts daily) 
r Breakfast — Egg on toast (no coffee). 
Melancholia. -j Dinner — Steak (rare) or chops, fresh vegetables. 

I Supper — Gruel, sauce (apple), custard or boiled -egg. 

Milk, one quart. 

Three eggs. 

Cod-liver oil. 

Whisky. 
■{ Sugar. 



Melancholia, re- 
fusing food fed 

by tube twice j ~~f~ 
... Salt. 



j Pancreatin, three grains. 

Pepsin, three grains. 
[ Sodium bicarbonate, fifteen grains. 

This amount given twice a day is varied once a week by chicken 
or mutton broth. 

" Two of the patients fed by tube with this combination for over 
a year remained in good condition " (Steele). 



HOSPITAL DIETARIES 



793 



Full Dietaries for Children at Various English Hospitals (Chambers) 



Age. 


Bread. 


Butter. 
I OZ. 

? 


Milk. 


Meat. 


Vegeta- 
bles. 


Under 7. 
Under 7. 


Un- 
limited. 
12 oz. 


ipt. 


2 OZ. 
2 oz. 


4 oz. 
3 oz. 


Under 8. 


5£oz. 


About 
} oz. 


ipt- 


2 OZ. 


4 oz. 


Under 8. 


8 oz. 


About 


? 


2 OZ. 


4 oz. 


Above 8. 
Under 9. 


8 oz. 
6 oz. 


I oz. 

About 

1 oz. 

? 


Ipt- 
ipt. 


3 oz. 
broth, 
ipt- 

2 OZ. 


6 oz. 

6 oz. 


Under 9. 
Under 10. 
Under 10. 


7 oz. 
12 oz. 
6 oz. 


\ oz. 
f oz. 

? 


ipt. 
ipt. 

lipt. 


4 oz. 
2 oz. 
2 eggs. 


4 oz. 
4 oz. 

? 



Pudding. 



Hospital. 



Unlimited. St. George's. 
London. 



Twice 
a week. 
i pint. 



Children's Hospital, 
Great Ormond Street, 
and Evelina Hospi- 
tals. 

Leeds Infirmary. 



Gruel, Children's, Great Or- 
\ pint. mond Street, and 

Evelina Hospitals. 
\ pint gruel Birmingham General 
or broth, j Hospital. 
To order, j St. Bartholomew's. 
6 oz. ' St. Thomas's. 
8 oz. j King's College. 



Diet of Northeastern Hospital for Children, London 





Milk diet. 


Fish diet. 


Full diet. 


Breakfast, 7 A. M. . . . 


Milk, \ pt. ; bread, 


Milk or cocoa, -£ pt. ; 


Milk or cocoa, \ pt. ; 




2 oz., with butter. 


bread, 2-Joz., with 


bread, i\ oz., with 






butter. 


butter. 


Dinner, 12 M 


Milk, ■£ pt. ; rice or 


Fish, boiled, 2-J oz. ; 


Roast, boil'd, or minc'd 




other milk pud- 


potatoes, mashed, 


mutton, or roast or 




ding. 


3 oz ; bread, 1 


minced beef, i\ oz. ; 






oz. ; milk pud- 


mashed potatoes, 4 






ding. 


oz., to alternate with 
green vegetables ; 
bread, 1 oz. ; milk 
pudding. 


Tea, 3.30 p. M 


Milk, i pt. ; bread, 


Milk, £ pt. ; bread, 


Bread, i\ oz., with but- 




2 oz., with butter. 


2 -J oz., with trea- 


ter, treacle, or drip- 






cle or butter. 


pings ; milk, \ pt. 


Supper, 6 p. m 


Biscuit (cracker) or 


Bread, 2 oz., with 


Bread, 2 oz., with but- 




slice of bread and 


butter, or cracker. 


ter, or cracker. 




butter. 







DIETARIES OF ARMY HOSPITALS 

United States Army Hospitals 

Special Diet. — The medical officer will select from this list ac- 
cording to his discretion : Bread, butter, coffee, tea, toast (dry), toast 
(milk), eggs (boiled), eggs (poached), milk, beefsteak, milk por- 
ridge, ham, beef extract, oatmeal mush and milk, chicken (stewed), 
chicken broth, mutton chop, mutton broth, chocolate, oysters 



794 RATIONS, DIETARIES 

(stewed), beef tea, rice (boiled), farina pudding, cornstarch, crack- 
ers (soda or cream), potatoes (baked), potatoes (mashed), beef es- 
sence, macaroni (boiled), canned peaches (stewed), canned apples 
(stewed), canned pears, grapes, oranges, lemons, apples, water- 
melons, cantaloupes, etc. 

The following comprises the list of articles allowed in the ration 
of the U. S. A. post hospitals : 

Breakfast 

Bread 6 ounces. 

Butter \ ounce. 

Coffee i pint. 

Tea I " 

Toast, dry 4 ounces. 

Toast, milk 6 " 

Eggs, boiled 1 

Eggs, poached 1 

Milk 12 ounces. 

Beefsteak 6 " 

Milk porridge 1 pint. 

Ham 4 ounces. 

Beef essence 2 " 

Dinner 

Bread 4 ounces. 

Chicken, stewed 6 " 

Chicken broth 1 pint. 

Mutton chop 6 ounces. 

Mutton broth I pint. 

Milk 12 ounces. 

Oysters, stewed 1 gill. 

Beef tea 12 ounces. 

Rice, boiled 1 ounce. 

Farina pudding 4 ounces. 

Cornstarch pudding 4 " 

Milk porridge 1 pint. 

Beefsteak 6 ounces. 

Potatoes, mashed 6 " 

Beef essence 2 " 

Supper 

Tea 1 pint. 

Butter -£- ounce. 

Bread 4 ounces. 

Toast, dry 4 " 

Milk 12 " 

Eggs 1 

Milk porridge 1 pint. 

Beef essence 2 ounces. 



HOSPITAL DIETARIES 



795 



Following is the diet list issued in 1900 for a large United States 
Army General Hospital (at the Presidio of San Francisco) : 

United States Army General Hospital 



Breakfast. 



Dinner. 



Supper. 



Sunday. 
Oatmeal and milk. 
Ham and eggs. 
Bread and butter. 
Fruit. 
Coffee. 

Monday. 
Germea and milk. 
Beefsteak. 
Fried potatoes. 
Bread and butter. 
Fruit. 
Coffee. 

Tuesday. 
Oatmeal and milk. 
Sausage. 
Fried potatoes. 
Bread, butter, coffee. 
Fruit. 

Wednesday. 
Milk toast. 
Beefsteak. 

Bread, butter, coffee. 
Fruit. 

Thursday. 
Germea and milk. 
Hash. 

Bread, butter, coffee. 
Fruit. 

Friday. 
Oatmeal and milk. 
Bacon and eggs. 
Bread, butter, coffee. 
Fruit. 

Saturday. 
Germea and milk. 
Beefsteak. 
Fried potatoes. 
Bread, butter, coffee. 
Fruit. 



Vermicelli soup. 
Roast veal, sage dressing, or 
Turkey or chicken and dressing. 
Stewed peas. Mashed potatoes. 
Farina pudding. Fruit. 
Bread and butter. Coffee. 

Roast beef. 

Mashed potatoes. String beans. 

Tapioca pudding. 

Bread and butter. Fruit. 

Coffee. 



Vegetable soup. 

Baked pork and beans. 

Baked tomatoes. 

Bread pudding. 

Bread, butter, cocoa, fruit. 

Roast mutton with dressing. 
Mashed potatoes. 
Corn or fresh vegetables. 
Chocolate pudding. Fruit. 
Bread, butter, coffee. 

Oyster soup. 

Corned beef and cabbage. 
Boiled potatoes. Radishes. 
Rice pudding. Fruit. 
Bread, butter, coffee. 

Baked fish with sauce. 
Plain boiled potatoes. 
; Fresh salad. 
Farina pudding. Fruit. 
Bread, butter, cocoa. 

1 Roast beef, veal, or pork. 

Mashed potatoes. 

Hot slaw. Cauliflower. 

Bread pudding. 
, Bread, butter, coffee. 



Veal stew or boiled ham. 

Apple sauce. 

Cake. 

Bread and butter. 

Tea. 



Codfish balls or hash. 

Bread and butter. 

Pickles. 

Jam. Sweet crackers. Prunes. 

Tea. 



Fried liver and bacon. 

Corn bread and sirup or 

Biscuits 

Bread, butter, tea. 

Fruit. 

Mutton stew. 
Pickles. Sweet crackers. 
Bread, butter, tea. 
Peach cobbler. 



Sliced roast beef. 

Macaroni and cheese. 

Preserves. 

Bread and butter. 

Tea. 

Salmon salad. Potato salad. 

Apple sauce. 

Ginger crackers. 

Bread and butter. 

Tea. 

Baked hash or stew. 
Stewed prunes. 
Assorted cakes. 
Bread and butter. 
Tea. 



796 



RATIONS, DIETARIES 



[/ LIGHT DIET 



Breakfast. 


Dinner. 


Supper. 


Sunday. 






Oatmeal and milk. 


Rice soup. 


Milk toast. 


Soft-boiled eggs. 


Farina pudding. 


Cup custard. 


Milk toast. Coffee. 


Coffee. 


Tea. 


Monday. 






Germea and milk. 


Plain tomato soup. 


Farina mush and milk. 


Milk toast. 


Bread pudding with lemon sauce. 


Sweet crackers. Jelly. 


Boiled eggs. 


Coffee. 


Toast. 


Coffee. 




Tea. 


T ties day. 






Oatmeal and milk. 


Barley soup. , 


Biscuits or corn bread. 


Boiled eggs. 


Tapioca pudding. 


Maple sirup. Boiled rice. 


Coffee. 


Cocoa. 


Milk toast and tea. 


Wednesday. 






Oatmeal and milk. 


Consomme vermicelli. 


Sweet crackers. Jam. 


Soft-boiled eggs. 


Cornstarch pudding. 


Milk toast. 


Coffee. 


Vanilla sauce. Coffee. 


Tea. 


Thursday. 






Germea and milk. 


Oyster soup. 


Macaroni and cheese. 


Boiled eggs. 


Rice pudding. 


Milk toast. Maple sirup. 


Coffee. 


Coffee. 


Tea. 


Friday. 






Oatmeal and milk. 


Fish chowder. 


Tapioca pudding. 


Boiled eggs. 


Farina pudding. 


Milk toast. Ginger crackers. 


Milk toast. 


Cocoa. 


Boiled eggs. 


Coffee. 




Tea. 


Saturday. 






Oatmeal and milk. 


Vermicelli soup. 


Germea mush. 


Boiled eggs. 


Sago pudding. 


Assorted cakes. Jelly. 


Coffee. 


Coffee. 


Milk toast. 
Tea. 



HOSPITAL DIETARIES 



797 



In addition to the regular diet table a special diet list is pro- 
vided for use of ward surgeons for cases requiring this class of diet 
it also contains a list of broths intended for liquid diets. 

Daily Order List of Special Diet 

U. S. A. General Hospital, 
Ward Presidio of San Francisco, igoo. 





B. 


D. 


S. 








Number of light diets 














Number of full diets 








Stewed chicken 














Chopped beef 




Steaks 




Mutton chops 




Baked potatoes 

French-fried potatoes 




Saratoga chips 

Creamed potatoes 




Baked apples 




Wine jelly 

Cup custard 




Milk toast 

Poached eggs 




Coffee 




Tea 








Broths 
Beef broth 














Mutton broth 




Chicken broth 


i 

i 
! 




Consomme broth 




Oyster broth 









Ward Officer. 



British Army Hospitals 

The following statement is quoted from a report made by Col. 
Alfred A. Woodhull, who was sent abroad by the U. S. Army De- 
partment to investigate certain medical features of the British army : 

''The British army uses seven [diets], known as tea, milk, beef 
tea, chicken, convalescent, roast, and varied. Each is formulated 
with exactness, and parts of two diets may not be ordered together. 
The tea diet is : Bread, twelve ounces ; tea, half an ounce ; sugar, 
two and a half ounces; milk, six ounces. The varied diet is: Beef 
or mutton, twelve ounces without, or fifteen ounces with, bone ; 
bread, eighteen ounces ; tea, half an ounce ; sugar, one and a half 
ounce ; milk, six ounces ; butter, one ounce ; potatoes, sixteen 
ounces ; vegetables, four ounces, with salt, pepper, and mustard, and 



79 8 



RATIONS, DIETARIES 



optionally wine, spirits, malt liquors, and diet drinks may be ordered. 
These diets represent the extremities of the scale through which 
the others run. The ordinary drinks allowed for patients are : 
Barley water, rice water, gruel, and lemonade, each prepared by 
formula." 

Prussian Army Hospitals 

According to Roth and Lex, in four grades of diet in Prussian 
military hospitals the proportionate allowance of food classes is as 
follows : 





I. 


II. 


III. 


IV. 


Albumin 


ii5 

55 

522 


81 

39 

315 


52 

32 

179 


18 


Fat 


15 
127 


Carbohydrates 





French Army Hospitals 

Kirchner gives the following analysis of the nutrient ingredients 
of the seven different classes into which diet in the French military 
hospitals is divided. " Absolute diet " (diete absolue) is practical 
starvation, at most, only a little toast water being given, and is of 
service for such cases as may require exclusive rectal feeding. 





Albumin. 


Fats. 


Carbohydrates. 


Full diet 


Grammes. 
119 

91 
70 

35 
19 
14 


Grammes. 

57 
47 
39 
25 
17 
36 


Grammes. 
448 

357 
225 

134 

89 
89 


f- diet 


\ " 


| " 


i " 

Bread diet 


Absolute diet 







APPENDIX 



RECEIPTS FOR INVALID FOOD AND BEVERAGES, 
SUITABLE FOR FEVERS AND CONVALESCENCE 
FROM ACUTE ILLNESS 



BEVERAGES 

i. Demulcent and Nutritive 

Barley Water (Pavy). — Take two ounces of pearl barley and 
wash well with cold water, rejecting the washings. Afterwards boil 
with a pint and a half of water for twenty minutes in a covered 
vessel, and strain. The product may be sweetened and flavoured 
with lemon peel, or lemon peel may be introduced while boiling is 
carried on. Lemon juice is also sometimes added to flavour. A 
bland, demulcent, and mildly nutritive beverage. 

Barley Water (Bartholow). — Wash two ounces of pearl barley 
with cold water. Then boil it for five minutes in some fresh water, 
and throw both waters away. Then pour on two quarts of boiling 
water, and boil it down to a quart. (Stir and skim occasionally.) 
Flavour with thinly cut lemon rind ; add sugar to taste, but do not 
strain unless at the patient's request. 

Barley Water (Ringer). — To a tablespoonful of pearl barley 
washed in cold water add two or three lumps of sugar, the rind of 
one lemon, and the juice of half a lemon. On these pour a quart 
of boiling water, and let the mixture stand for seven or eight hours. 
Strain. The barley water should never be used a second time. Half 
an ounce of isinglass may be boiled in the water. If not needed at 
once, these barley preparations should be kept in the refrigerator 
and warmed when required. 

Rice Water or Mucilage of Rice (Pavy). — Thoroughly wash one 
ounce of rice with cold water. Then macerate for three hours in 
a quart of water kept at a tepid heat, and afterwards boil slowly 
for an hour, and strain. A useful drink in dysentery, diarrhoea, and 
irritable states of the alimentary canal. It may be sweetened and 
flavoured in the same way as barley water. 

799 



800 APPENDIX 

Demulcent Drink (Ringer). — Take a pinch of isinglass, and boil 
it in half a pint of new milk with half a dozen bruised sweet almonds 
and three lumps of sugar. 

Linseed Tea (Chambers). — Whole linseed, white sugar, each one 
ounce ; licorice root, one half ounce ; lemon juice, two ounces. Mix. 
An agreeable demulcent. 

Flaxseed Tea. — One half cupful of flaxseed to one quart of boil- 
ing water ; boil thirty minutes and let stand a little while near the 
fire to thicken more. Strain, and add lemon juice and sugar. 

Currant Jelly (Fagge). — Red or black currant jelly, dissolved in 
hot or cold water or strained tamarind tea, make excellent invalid 
beverages. 

2. Diuretic and Refrigerant 

Lemonade (Pavy). — Pare the rind from a lemon thinly, and cut 
the lemon into slices. Put the peel and sliced lemon into a pitcher 
with one ounce of white sugar, and pour over them one pint of 
boiling water. Cover the pitcher closely, and let stand until cold. 
Strain or pour off the liquid. 

Citron may be used instead of lemon, and it likewise furnishes a 
grateful and refrigerant beverage. 

Lemonade, Effervescing (Ringer). — To the expressed juice of a 
large lemon add a lump or two of sugar previously lightly rubbed 
on the rind. Pour on it half a pint of cold or iced water. To cause 
it to effervesce put it into a large tumbler and add half a teaspoon- 
ful of bicarbonate of soda or potash. Stir and drink while effer- 
vescing. A very agreeable and refreshing beverage. 

Lemonade (Ringer). — Pare the rind of three lemons as thin as 
possible, add one quart of boiling water and a quarter of an ounce 
of isinglass. Let them stand till next day covered ; then squeeze 
the juice of eight lemons upon half a pound of lump sugar; when 
the sugar is dissolved, pour the lemon and water upon them, mix 
all well together, strain, and it is ready for use. 

Orangeade (U. S. Army Hospitals). — One orange. One tea- 
spoonful of sugar. Three fourths of a coffee cup of water (six 
ounces). Wash and wipe the orange. Squeeze the juice into the 
sugar. Add the cold water, previously boiled. Strain and serve. 

Cream-of-tartar Drink. — Potus Imperialis. — Imperial Drink 
(Pavy). — Dissolve a drachm or a drachm and a half of cream of 
tartar in a pint of boiling water, and flavour with lemon peel and 
sugar. When cold, strain and take ad libitum as a refrigerant drink 
and diuretic. 

Cream-of-tartar Whey (Pavy). — Stir a quarter of an ounce of 
cream of tartar (a large teaspoonful piled up) into a pint of boiling 
milk, and strain. A refrigerant and diuretic drink, which is ren- 
dered more agreeable by the addition of sugar. 



FLUID BEEF PREPARATIONS 8oi 

White Wine Whey or Posset (Pavy). — To half a pint of milk 
while boiling in a saucepan add one wineglassful of sherry, and 
afterwards strain through a muslin cloth. Sweeten with pounded 
sugar according to taste. A useful diuretic drink in colds and mild 
febrile disorders. For a child, give a tablespoonful every two or 
three hours. 

Wine Whey. — Milk, one pint ; wine of pepsin, one teaspoonful. 
Heat gently to 115 or 120 F., let stand, break the curd, strain, 
and add sherry in the proportion of 1 to 4 or 6. Drink cold. 

Tamarind Whey (Pavy). — Stir two tablespoonfuls of tamarinds 
into a pint of milk while boiling, and afterwards strain. This forms 
a refrigerant and slightly laxative drink. 

Mulled Wine (Ringer). — Boil some spice, cloves, nutmeg, cinna- 
mon, or mace in a little water just to flavour the wine ; then add a 
wineglassful of sherry or any other wine and some sugar ; bring it 
to the boiling point, and serve with sippets of toast. If claret is 
used, it will require more sugar. The vessel for boiling the wine 
should be scrupulously clean. 

FLUID BEEF PREPARATIONS 

Beef Juice (Bartholow). — Broil quickly some pieces of round or 
sirloin of a size to fit in the cavity of a lemon squeezer previously 
heated by being dipped in hot water. The juice, as it flows away, 
should be received into a hot wineglass, and, after being seasoned 
to the taste with salt and a little Cayenne pepper, taken while hot. 

Beef Essence (Yco). — Cut the lean of beef into small pieces and 
place them in a wide-mouthed bottle securely corked, and then 
allow it to stand for several hours in a vessel of boiling water. This 
may be given to infants, who can not take milk, in teaspoonful doses, 
and in larger quantities to adults. 

Beef Tea (Germain See). — Meat cut into small pieces, cold water 
added, and then gradually heated to 140 or 160 F. Press, strain, 
and flavour with salt and pepper. This is much inferior to the 
preparations made with hydrochloric acid. 

Beef Tea {Pavy). — Put a pound of finely minced beef into a 
suitable vessel with a pint of cold water. Let it stand for an hour, 
stirring occasionally. Place the vessel containing the beef into a 
saucepan of water, place over the fire, and allow the water to boil 
gently for an hour (or the vessel containing the beef tea may be put 
into an ordinary oven for an hour). Pass the beef tea through a 
strainer. It contains a quantity of fine sediment, which should be 
drunk with the liquid. Flavour with salt. In this process the beef 
extract should not be exposed to a temperature of more than 170 F. 

Beef Tea (Bryee). — Lean beef, chopped fine, free from fibre, one 
pound ; water, one pint ; sodium bicarbonate, ten grains ; simmer 



802 APPENDIX 

half an hour in a glass-covered preserve jar, decant the fluid, squeeze 
the meat to a pulp in a lemon squeezer, return both to jar, add 
extract of pancreas, cover, keep at 140 F. for twelve hours^ shaking 
occasionally. When an acid taste appears, boil two or three minutes 
to stop further fermentation. 

This tea, it is claimed, equals the same bulk of peptonised milk 
in nutrient value. 

Chrystie's Beef Tea. — Macerate for one hour one pound of finely 
minced lean beef in a pint of water, containing fifteen grains of 
sodium chloride and five drops of dilute hydrochloric acid, at ioo° F. 

Filter through cheese cloth, and wash the residue with half a pint 
of fresh water. The filtrate is transparent, has a not unpleasant 
taste, and contains a considerable amount of albuminoids. A child 
of two years may take two or three ounces daily. 

Beef Tea (Bartholozv). — Chop fine a pound of lean beef free from 
fat, tendons, etc., and digest with a pint of cold water for two hours. 
Let it simmer on the stove for three hours, at a temperature never 
over 160 F. Make up the water lost in evaporation by adding cold 
water, so that a pint of beef tea shall represent a pound of beef. 
Strain, and carefully express all fluid from the beef. 

Beef Tea (U. S. Army Hospital Receipt for Twelve Men).— Bed, 
twelve pounds ; salt, one ounce. 

Directions. — The beef should be lean and juicy, and cut into small 
pieces. Put it into one gallon and a half of cold water with the 
salt. Let it boil gently three hours. If it should boil away too 
fast, add the requisite quantity of boiling water and let it boil fifteen 
minutes longer. When done it should measure twelve pints. Set it 
aside to cool. Remove every particle of grease, and heat when 
required. In case of a deficiency of fresh beef, use the beef extract 
supplied in the hospital stores. 

Beef Extract (U. S. Army Hospital Receipt for Twelve Men). 

Directions. — Infuse a third of a pound of fresh beef, finely minced, 
in fourteen ounces of cold soft water, to which a few drops (four or 
five) of muriatic acid and a little salt (from ten to eighteen grains) 
have been added. After digesting for an hour to an hour and a 
quarter, strain it through a sieve and wash the residue with five 
ounces of cold water, pressing it to remove all soluble matter. The 
mixed liquid will contain the whole of the soluble constituents of the 
meat (albumin, creatin, etc.), and it may be drank cold or slightly 
warmed. The temperature should not be raised above ioo° F., as 
at the temperature of 113 F. a considerable portion of the albumin, 
a very important constituent, will be coagulated. 

Meat Extract (Rosenthal and Lcube). — One thousand giammes of 
lean meat, minced fine, are placed in a porcelain vessel with one 
thousand grammes of water, and twenty centigrammes of dilute 
hydrochloric acid. This is placed in a closed Papin's digester and 



BROTHS AND SOUPS 803 

boiled for ten to fifteen hours. The mass is then taken out and 
rubbed in a mortar to a paste. It is again boiled in the closed 
digester for another sixteen to twenty hours ; after this it is neutral- 
ised with pure sodium carbonate, and evaporated to a sirupy con- 
sistence. 

Restorative Beef Essence (Ringer). — Take one ounce of fresh 
beef, free from fat, chop fine, and pour over it eight ounces of soft 
water, add five or six drops of dilute hydrochloric acid, and fifty 
or sixty grains of common salt, stir it well, and leave for three hours 
in a cool place. Then pass the fluid through a hair sieve, pressing 
the meat slightly, and adding gradually toward the end of the strain- 
ing about two more ounces of water. The liquid thus obtained is of a 
red colour, possessing the taste of soup. It should be taken cold, a 
teaspoonful at a time. If preferred warm, it must not be put on the 
fire, but heated in a covered vessel placed in hot water. 

BROTHS AND SOUPS 

Chicken Broth (Bartholozv). — Skin and chop up fine a small 
chicken or half a large fowl, and boil it, bones and all, with a blade 
of mace, a sprig of parsley, and a crust of bread, in a quart of water 
for an hour, skimming it from time to time. Strain through a coarse 
colander. 

Chicken, Veal, or Mutton Broth (Yeo). — Chicken, veal, or mutton 
broth may be made like beef tea, substituting chicken, veal, or mut- 
ton for beef, boiling in a saucepan for two hours, and straining. 
For chicken broth the bones should be crushed and added. For 
veal broth the fleshy part of the knuckle should be used. Either 
may be thickened and their nutritive value increased by the addition 
of pearl barley, rice, vermicelli, or semolina. 

Mutton and Chicken Broths (Osier). — Mince a pound of either 
chicken or mutton, freed from fat, put into a pint of cold water, and 
let stand in a cold jar on ice two to three hours. Then cook three 
hours over a slow fire, strain, cool, skim off fat, add salt, and serve 
hot or cold. Such broth is much better than any manufactured meat 
preparations. Good mutton broth is difficult to make on account of 
the meat containing so much fat. 

Chicken Broth (U. S. Army Hospital Receipt for Tzvehe Men). — 
Chicken, one ; salt, two ounces ; flour, two ounces. 

Directions. — Cut the chicken into pieces. Put it with the salt into 
the kettle with twelve pints of cold water. Let it simmer gently 
two or three hours, carefully and frequently skimming off the grease. 
Make a paste of the flour with some cold water ; stir it in and boil 
ten minutes longer. It should measure ten pints when done. 

Mutton Broth (U. S. Army Hospital Receipt for Twelve Men).— 
Mutton, six pounds ; salt, two ounces ; rice, two ounces. 



804 APPENDIX 

Directions. — Break the bones without separating the meat. Put 
it into twelve pints of cold water, with the salt and rice or barley. 
Boil gently two hours and a half, carefully removing all the scum 
and fat. If the broth should boil away too much, add the requisite 
quantity of boiling water to make twelve pints, and let it boil fifteen 
minutes longer. 

Invalid Broths. — To one pound of chopped lean meat, either 
chicken, mutton, or beef, add one pint of cold water (or one pint 
and a half on ice for a young infant), let stand in a covered glass 
fruit jar for four to six hours, cook for three hours in a closed jar 
over a slow fire, strain, cool, skim off the fat, clear with egg, season, 
and feed warm or cold. 

Bouillon (Broth) as used in the Hospitals of Paris (Yea), — Raw 
meat, without bone, one kilogramme ; fresh vegetables, four hun- 
dred grammes (about one pound) ; salt, ten grammes (about one 
hundred and fifty grains). Boil very slowly over a gentle fire. 

Nourishing Soup (Ringer). — Stew two ounces of the best well- 
washed sago in a pint of water till it is quite tender and very thick ; 
then mix it with half a pint of good boiling cream and the yolks of 
two fresh eggs. Blend the whole carefully with one quart of essence 
of beef. The beef essence must be heated separately, and mixed 
while both mixtures are hot. A little of this may be warmed at a 
time. 

Consomme. — Consomme may be flavoured with vegetable extracts 
or expressed juice of vegetables boiled in it. Thicken soups with 
arrowroot, ground rice, or cornflour. 

Beef Tea with Oatmeal (Anderson). — This forms a very nutritious 
food. Take two tablespoonfuls of oatmeal and two of cold water 
and mix them thoroughly ; then add a pint of good beef tea which 
has just been brought to the boiling point. Boil together for five 
minutes, stirring it well all the time, and strain through a hair 
sieve. 

SOLID MEAT PREPARATIONS 

Raw-meat Diet (Ringer). — From two ounces of rump steak take 
away all fat, cut into small squares without entirely separating the 
meat, place in a mortar, and pound for five or ten minutes ; then add 
three or four tablespoonfuls of water and pound again for a short 
time, afterwards removing all sinew or fibre ; add salt to taste. Be- 
fore using, place the cup or jar containing the pounded meat in 
hot water until just warm. 

Or scrape the beefsteak with a sharp knife and, after removing 
all fat and tendon, if not already in a complete pulp, pound in a 
mortar. Flavour with salt and pepper. This may be taken in the 
form of a sandwich between thin bread and butter or mixed with 
water to the consistence of cream. If preferred, the meat may be 



SOLID MEAT PREPARATIONS 805 

rolled into balls with a little white of egg and broiled for two min- 
utes, or until the outside turns gray — just long enough to remove 
the raw taste. 

This diet is excellent for children with diarrhoea, also for adults 
who suffer from irritable bowels or chronic diarrhoea. 

Scraped Beef (U. S. Army Hospitals). — Cut a piece of steak 
from the round, about half a pound in weight and about an 
inch thick. Lay it on a clean meat board and with a dull knife 
scrape out the pulp until there is nothing left but stringy fibre. 
Season the scraped pulp with salt and make it into small cakes. 
Broil for two minutes either by direct heat over a clear fire, or by 
heating a clean pan or plate and, when hot, placing the meat on it. 
Have both sides cooked sufficiently. This is a safe food for a patient 
beginning to take solid nourishment. Scraped beef may be prepared 
very easily over an alcohol lamp. 

Scraped-beef Sandwiches (U. S. Army Hospitals). — Place a piece 
of round steak on a meat board and scrape out all of the pulp with 
a dull knife ; add to the pulp a little salt and pepper and enough 
raw beef juice to make it into a firm jelly. Have stale bread cut 
into very thin slices and spread the beef pulp on them; cut the 
sandwiches quite small. Never use butter in making beef sand- 
wiches. 

Meat Biscuits (Parkes). — Mix together, cook, and bake one 
pound of flour, one pound of meat, one quarter of a pound of suet, 
one half pound potatoes with a little sugar, onion, salt, pepper, and 
spices. A palatable meat biscuit, weighing about one pound and a 
quarter, containing 10 to 12 per cent of water, is thus obtained which 
keeps quite unchanged for four months. 

Raw-meat Sandwiches (from Food). — Three ounces of raw beef 
or mutton, one ounce of very fine bread crumbs, one teaspoonful 
of sugar ; cut the meat very fine, rub it through a hair sieve, then 
pound it in a mortar into a paste. Mix with it the bread crumbs, 
sugar, a little salt and pepper ; spread it between thin slices of either 
brown or white bread and butter. 

Chicken Jelly (Adams). — Clean a fowl that is about a year old, 
remove skin and fat ; chop fine, bones and flesh, place in pan with 
two quarts of water ; heat slowly ; skim thoroughly ; simmer five to 
six hours ; add salt, mace, or parsley to taste, strain ; cool. When 
cool, skim off the fat. 

The jelly is usually relished cold, but may be heated. Give often 
in small quantities. 

Enema of Meat and Pancreas (Lcubc). — Mince from one hundred 
and fifty to three hundred grammes of meat, and mix with fifty to 
one hundred grammes of finely chopped pancreas, free from fat. 
Beat the mixture into a paste with a pestle or spoon, adding a little 
lukewarm water to make it of a suitable consistence for injection 



806 APPENDIX 

through the enema tube. Use warm ; if cold it may excite the rec- 
tum and cause expulsion. If thought desirable, from twenty-five to 
fifty grammes o£ fat may be mixed intimately with the mass by 
the help of a warm pestle. A syringe with a wide nozzle must 
be used. 

MILK PREPARATIONS 

Milk-and-cinnamon Drink (Ringer). — Boil in one pint of new 
milk sufficient cinnamon to flavour it pleasantly, and sweeten with 
white sugar. This may be taken cold with a teaspoonful of brandy, 
and is very good in cases of diarrhoea. Children may take it warm 
without brandy. 

Albuminised Milk (U. S. Army Hospitals). — Beat up the white of 
an egg till light. Add a good-sized pinch of salt, and four ounces 
of fresh, cool milk which has been sterilised. A little sugar may 
be added if desired. 

Milk Punch. — Make by adding brandy or whisky or rum to milk 
in the proportion of about one to four or six parts of milk ; flavour 
with sugar and nutmeg ; shake well. 

Sherry or Brandy and Milk (Ringer). — To one tablespoonful of 
brandy or one wineglassful of sherry, in a bowl or cup, add pow- 
dered sugar and a very little nutmeg to taste. Warm a breakfast 
cupful of new milk and pour into a pitcher. Pour the contents from 
a height over the wine, sugar, etc. The milk must not boil. 

Rum and Milk (F other gill). — Half a pint of new milk, one egg, 
one to two teaspoonfuls of powdered sugar, grated nutmeg, one to 
two teaspoonfuls of good old Jamaica rum. Mix. 

Junket (Anderson). — Sweeten with white sugar one pint of good 
milk. If wine is allowed, a dessertspoonful of sherry is an improve- 
ment. Heat to new milk warmth, pour into a shallow dish, and stir 
in two teaspoonfuls of essence of rennet. This will form a slight 
curd. Grate a little nutmeg over it or add a pinch of powdered 
cinnamon. Serve when quite cold. In cold weather the milk should 
be placed in a warm room to set. An excellent food, and good sub- 
stitute for milk in typhoid fever, etc. 

Artificial Human Milk (Frankland). — Allow one third of a pint 
of new milk to stand twelve hours, remove the cream, and mix it 
with two thirds of a pint of perfectly fresh cow's milk. Take the 
milk from which the cream was removed and put a piece of rennet 
about an inch square (fluid rennet may be employed) into it. Keep 
the vessel containing it in a warm place until the milk is fully 
curdled, an operation requiring five to fifteen minutes, according 
to the activity of the rennet, which should be removed as soon 
as the curdling commences, and put into an eggcup for use on 
subsequent occasions, as it may be employed daily for a month or 
two. Break up the curd repeatedly, and carefully separate the whole 



EGG PREPARATIONS 807 

of the whey, which should then be rapidly heated to boiling in a 
small tin pan, placed over a spirit or gas lamp. During the heating 
a further quantity of casein [albumin?], technically called " fleet- 
ings," separates, and must be removed by straining through clean 
muslin. Now dissolve one hundred and ten grains of powdered 
sugar of milk in the hot whey, and mix it with two thirds of a pint 
of new milk to which the cream from the other fluid has already 
been added, as already described. The artificial milk should be used 
within twelve hours of its preparation. 

Biedert's Cream Mixture. — Mix four ounces of cream with twelve 
ounces of warm water and add one half ounce of milk sugar. 

Koumiss (Anderson).— -To one pint of new milk add three ounces 
of water, three ounces of old koumiss (for a ferment), and one ounce 
of saturated solution of sugar of milk. Put all in a large jug, cover 
carefully, and set the jug in a warm place for twenty-four hours. 
By that time a thick crust will have formed on the surface of the 
mixture ; beat this up thoroughly and mix all well. Then put the 
whole into champagne bottles, which should be no more than two 
thirds full, and cork and wire. Shake the bottles daily. The kou- 
miss will be fit for use in two days, but it is much improved by 
keeping for about six weeks. It should be drawn off with a tap. 

Home-made Koumiss. — Boil fresh milk, and when nearly cold 
put into quart bottles, leaving room to shake. Add half an ounce 
of crushed lump sugar and a piece of Vienna yeast the size of a 
hazel nut (i. e., twenty grains), cork with new corks, tie down, keep 
cool, lay the bottles horizontal, but shake twice daily. Ready to 
drink on sixth day, or earlier in hot, later in cold weather. 

The koumiss can be made thinner by using skimmed milk. 

Home-made Lime Water. — Pour two quarts of hot water over 
fresh, unslacked lime (size of a walnut), stir till slacked, let stand 
till clear and bottle. Often ordered with milk to neutralise acidity 
of the stomach. 

EGG PREPARATIONS 

Eggnog. — Eggnog is made by adding the beaten yolk of egg and 
a little spirits to a tumblerful of milk, stirring well, adding sugar and 
the white of the egg, separately beaten. The digestibility of both of 
these highly nourishing and stimulating preparations is enhanced by 
the addition of half an ounce of lime water, which does not affect 
the taste. 

Egg and Wine (Ringer). — Take one egg, half a glass of cold 
water, one glass of sherry, sugar, and a very little nutmeg grated. 

Beat the egg to a froth with a tablespoonful of cold water. Make 
the wine and water hot, but not boiling ; pour on the egg, stirring 
all the time. Add sufficient sugar to sweeten, and a very little nut- 
meg. Put all into a porcelain-lined saucepan over a gentle fire and 
53 



808 APPENDIX 

stir one way till it thickens, but do not let it boil Serve in a glass 
with crisp biscuits or sippets of toast. 

Eggnog (Bartholow). — Scald some new milk by putting it, con- 
tained in a jug, into a saucepan of boiling water, but it must not be 
allowed to boil. When quite cold beat up an egg with a fork in a 
tumbler with some sugar ; beat quite to a froth ; add a dessertspoon- 
ful of brandy and fill up the tumbler with scalded milk. A nutritive 
drink in acute disease. 

Brandy and Egg Mixture (British Pharmacopoeia). — Rub together 
the yolks of two eggs and half an ounce of refined sugar, and add 
four ounces of Cognac and four ounces of cinnamon water. A more 
generally useful mixture may be made with half this quantity of 
brandy. 

Stokes's Cognac Mixture. — Best Cognac, distilled water, each 
fifteen ounces ; yolk of one egg ; sirup, six ounces. Mix. Give a 
tablespoonful every two or three hours. 

Egg and Brandy Mixture (Anderson). — Beat up three eggs to 
a froth in four ounces of cold w 7 ater and then add four ounces of 
brandy. Mix well and sweeten to taste. A little nutmeg may be 
added. Give a tablespoonful or so at a time. 

Lemonade with Eggs (Ringer). — The juice of four lemons, the 
rinds of two, half a pint of sherry, four eggs, six ounces of loaf 
sugar, one pint and a half of boiling water. 

Pare the lemon rind thinly, put it into a pitcher with the sugar, 
and pour the boiling water on it. Let it cool, then strain, and add 
the wine, lemon juice, and eggs, previously well beaten and strained. 
Mix all together and it is ready for use. 

Savoury Custard (Anderson). — Add the yolks of two eggs to a 
cupful of beef tea, with pepper and salt to taste. Butter a cup or 
jam pot, pour the mixture into it, and let it stand in a pan of boiling 
water till the custard is set. 

Milk for Puddings or Stewed Fruit (Ringer). — Boil a strip of 
lemon and two cloves in a pint of milk ; mix half a teaspoonful of 
arrow 7 root in a little cold milk and add it to the boiling milk ; stir it 
until about the consistence of cream. Have ready the yolks of 
three eggs beaten up well in a little milk. Take the hot milk off 
the fire and as it cools add the eggs and a tablespoonful of orange- 
flower water, stirring it constantly till quite cool. Keep it in a very 
cool place till required for use. 

Rice Soup (Ringer). — Take three ounces of rice, the yolks of two 
eggs, half a pint of cream or new milk, one quart of stock. 

Boil the rice in the stock and rub half of it through a tammy, 
put the stock in a stewpan, add the rest of the rice whole, and sim- 
mer gently for five minutes. Have ready the milk or cream, boiled. 
Beat the yolks of the eggs and mix them gradually with the cream. 
Take the soup off the fire, add the cream and egg, stirring them well 



FARINACEOUS FOODS 809 

together as you mix them. Heat gradually, but do not boil, or the 
eggs will curdle. 

A Gruel (Ringer). — Beat an egg to a froth, add a wineglass of 
sherry, flavour with a lump of sugar, a strip of lemon peel, and a 
little grated nutmeg. Have ready some gruel, very smooth and hot, 
stir in the wine and egg, and serve with crisp toast. Arrowroot may 
be made in the same way. 

Caudle (Yco). — Beat up an egg to a froth ; add a glass of sherry 
and half a pint of gruel. Flavour with a lemon peel, nutmeg, and 
sugar. 

FARINACEOUS FOODS 

Arrowroot Blancmange (Ringer). — Take two tablespoonfuls of 
arrowroot, three quarters of a pint of milk, lemon, and sugar to 
taste. 

Mix the arrowroot with a little milk to a smooth batter ; put the 
rest of the milk on the fire and let it boil, sweeten, and flavour it, 
stirring all the time, till it thickens sufficiently. Put into a mould 
till quite cold. 

Arrowroot Blancmange (U. S. Army Hospitals). — Two table- 
spoonfuls of arrowroot. Two thirds pint of hot water. Two table- 
spoonfuls of sherry or brandy. Two teaspoonfuls of sugar. 

Mix the arrowroot into a smooth paste with three tablespoonfuls 
of cold water. Add this to the hot water. Bring to a boil, stirring 
constantly till well blended and free from lumps. Let boil for ten 
minutes. Add the sugar and sherry or brandy. Beat up quickly 
and pour into a bowl or mould to cool. Arrowroot blancmange may 
be made with fresh hot milk or condensed milk diluted. If boiling 
water is used it causes the starch of the arrowroot, when first poured 
in, to form into lumps. Hence it is best to have the water not quite 
at boiling point. 

Arrowroot (Pavy). — Mix thoroughly two teaspoonfuls of arrow- 
root with three tablespoonfuls of cold water, and pour on them half 
a pint of boiling water, stirring well meanwhile. If the water is quite 
boiling, the arrowroot thickens as it is poured on, and nothing more 
is necessary. If only warm water is used, the arrowroot must be 
afterwards boiled until it thickens. Sweeten with loaf sugar and 
flavour with lemon peel or nutmeg, or add sherry, port wine, or 
brandy, if required. Boiling milk may be employed instead of water, 
but when this is done no wine must be added, as it would otherwise 
curdle. 

Oatmeal Gruel (plain) (from Food). — Two tablespoonfuls of oat- 
meal, one saltspoonful of salt, one scant teaspoonful of sugar, one 
cupful of boiling water, one cupful of milk. Mix the oatmeal, salt, 
and sugar together, and pour on the boiling water. Cook for thirty 
minutes ; then strain through a fine wire strainer to remove the hulls, 



8lO APPENDIX 

place again on the stove, add the milk, and heat just to the boiling 
point. Serve hot. 

Scotch Beef Broth. — To a pint of beef broth which has been care- 
fully strained and seasoned and from which all the fat has been 
removed, add a teaspoonful of oatmeal and boil gently for two hours. 
Strain and serve hot. 

In this preparation the oatmeal should be soft and jellylike, and 
if too much water evaporates during the boiling, more should be 
added. 

Cornstarch (U. S. Army Hospital Receipt for Twelve Men). — 
Cornstarch, six ounces ; milk, three pints ; water, twelve ounces. 

Directions. — Mix the cornstarch into a smooth paste with 
cold water. The milk and water must be boiling, to which add 
a little salt. Stir in the cornstarch. Let it boil three or five 
minutes. 

Farina Pudding (U. S. Army Hospital Receipt for Twelve Men). — 
Farina, half a pound ; milk, two pints ; water, one pint ; sugar, two 
and a half ounces ; eggs, four ounces ; nutmeg, half an ounce. 

Directions. — Put the water into a stewpan with a little salt. When 
it boils, stir in the farina. Let it boil twenty minutes. Stir in the 
milk, which must be hot. Beat the eggs until they are very light ; 
mix the sugar with them. Stir in the eggs and sugar with the 
farina. Add the spice. Put it into a moderate oven and bake a half 
or three quarters of an hour. 

Farina Gruel (U. S. Army Hospitals). — One tablespoonful of 
farina. One pint of water. One teaspoonful of sugar. One half 
teaspoonful of salt. Into one pint of water, raised to boiling, put 
a half teaspoonful of salt ; then add the farina and cook for twenty 
minutes. Flavour with sugar and condensed milk, if fresh milk is 
not available. Strain and serve hot. 

In this recipe, as in others, condensed milk is used in a strength 
of one teaspoonful to the half pint of gruel. 

Boiled Rice (U. S. Army Hospital Receipt for Twelve Men). — 
Rice, twelve ounces ; salt, half an ounce ; water, three pints. 

Directions. — Put the salt and water into a stewpan. When boil- 
ing, add the rice, previously thoroughly washed. Boil for ten min- 
utes, or until each grain becomes soft. Drain it on a colander. 
Grease the stewpan with clarified drippings or lard. Put back the 
rice. Let it swell slowly near the fire, or in a slow oven, for about 
twenty minutes, until the grains are well separated. 

Rice Gruel (Chambers). — Ground rice, two ounces ; powdered cin- 
namon, quarter of an ounce ; water, four pints. Boil forty minutes 
and add a teaspoonful of orange marmalade. 

Rice Gruel (U. S. Army Hospitals). — Two tablespoonfuls of rice, 
or one tablespoonful of rice flour. One pint of boiling water. One 
half teaspoonful of salt. One teaspoonful of sugar. Wash the rice 



FARINACEOUS FOODS 8ll 

thoroughly in two waters, after removing any specks that may be 
mixed in the grain. Have the cooking water boiling. 

Rice Milk (Anderson). — Wash two tablespoonfuls of good rice 
and put it into a saucepan with a quart of milk. Let it simmer 
gently till the rice is tender, and stir from time to time to prevent 
burning; sweeten to taste. If desirable, serve with stewed apples 
or prunes. Sago, tapioca, etc., are prepared in the same way. If 
an egg is to be added, beat the white and yolk separately, and add 
them to the rice after it has been taken from the fire. 

Rice and Apple (Ringer). — Boil about two tablespoonfuls of rice 
in a pint and a half of new milk, and simmer, stirring it from time 
to time till the rice is quite tender. Have ready some apples, 
peeled, cored, and stewed to a pulp, and sweetened with a very 
little loaf sugar. Put the rice round a plate and the apple in the 
middle, and serve. 

Rice Cream (Ringer). — To a pint of new milk add a quarter of 
a pound of rice, a lump of butter the size of a walnut, a little lemon 
peel, and a tablespoonful of powdered sugar. Boil them together 
for five minutes, then add half an ounce of isinglass which has been 
dissolved, and let the mixture cool. When cool add half a pint of 
good cream whisked to a froth, mix together, and set it for a time 
in a very cool place, or on ice ; when used, turn it out of the basin 
into a dish, and pour fruit juice around it, or some stewed apple or 
pear may be served with it. 

Rice Cream (from Food, January, 1894). — Two tablespoonfuls of 
rice. Two cups of milk. One saltspoonful of salt. Two table- 
spoonfuls of sugar. Two eggs. 

Cleanse the rice by washing it several times in cold water ; cook 
it in a double boiler with the milk until the grains will mash. Three 
hours will generally be required to do this. Should the milk evap- 
orate, restore the amount lost. When the rice is perfectly soft, 
press it through a coarse soup strainer or colander into a saucepan, 
return it to the fire, and while it is heating beat the eggs, sugar, 
and salt together until very light. When the rice boils, pour the 
eggs in rather slowly, stirring lightly with a spoon for three or four 
minutes, or until it coagulates, and the whole is like a thick, soft 
pudding; then remove from the fire, and pour it into a dish. By 
omitting the yolks and using the whites of the eggs only, a delicate 
cream is obtained. 

Malt (Ground) and Rice Pudding (Yeo). — Stir an ounce of ground 
malt into a pint of boiling milk, strain through a sieve, and add 
the milk to two ounces of well-soaked rice. Mix well, and stand 
for ten minutes in a warm place, then bake for an hour. 

Cracker Gruel (from Food, January, 1894). — Two tablespoonfuls 
of cracker crumbs. One scant saltspoonful of salt. One scant tea- 
spoonful of sugar. One cup of boiling water. One cup of milk. 



812 APPENDIX 

To make the cracker crumbs, roll some crackers on a board until' 
they are fine. Water crackers are good, cream crackers are better ; 
mix the salt and sugar with the crumbs, pour on the boiling water, 
put in the milk, and simmer it for two minutes. The gruel does 
not need long cooking, for the cracker crumbs are already thor- 
oughly cooked. Do not strain. 

Indian-meal Gruel (from Food, January, 1894). — Two teaspoon- 
fuls of cornmeal. One tablespoonful of flour. One teaspoonful of 
salt. One teaspoonful of sugar. One quart of boiling water. One 
cup of milk. 

Mix the cornmeal, flour, salt, and sugar into a thin paste with 
cold water, and pour into it the boiling water. Cook it in a double 
boiler for three hours. No less time than that will cook the corn- 
meal thoroughly. Then add the milk, and it is ready to serve. 

Hard-bread Gruel (U. S. Army Hospitals). — Toast hard bread 
thoroughly and grind it into a powder. To one pint of boiling water, 
to which one half teaspoonful of salt has been added, add two 
tablespoonfuls of hard-bread powder. Boil ten minutes and then 
strain. Flavour with one teaspoonful of sugar and one teaspoonful 
of condensed milk to each cupful of the gruel. 

Bread Jelly (Chrystie). — Pour boiling water on stale bread, and 
let it soak for an hour. Pour off the water, add fresh water, and 
boil down until a thick mass is obtained which becomes jellylike 
on cooling, and may be eaten with milk or cream and sugar. 

Milk Porridge (U. S. Army Hospital Receipt for Ttvelve Men). — 
Milk, eight pints ; flour, twelve ounces ; water, three pints. 

Directions. — The flour to be used for milk porridge should be 
previously prepared by being tied up closely in a bag and boiled 
four or five hours. It can then be grated to powder, which should 
be mixed into a smooth paste with cold water. Add to the milk 
the prescribed quantity of water, and stir in the flour, with a little 
salt. Let it boil ten minutes, stirring all the time. 

Fothergill's Amylaceous Food. — Of rice, well washed, of arrow- 
root, tapioca, and pearl barley, take each an ounce, add two quarts 
of water, and boil down to a quart ; then flavour with candied eringo. 

Barley Jelly (Eustace Smith). — Put two tablespoonfuls of washed 
pearl barley into a pint and a half of water, and slowly boil down 
to a pint; strain, and let the liquid settle into a jelly. Two tea- 
spoonfuls of this, dissolved in eight ounces of warmed and sweet- 
ened milk, are enough for a single feeding, and such a meal may be 
allowed twice a day. 

Panada (Ringer). — Take the crumb of a penny roll and soak 
it in milk for half an hour, then squeeze the milk from it ; have 
ready an equal quantity of chicken or veal, scraped very fine with 
a knife ; pound the bread crumb and meat together in a mortar. 
It may be cooked either mixed with veal or chicken broth, or 



GELATIN PREPARATIONS 813 

poached like an egg. By taking it up in two spoons, in pieces 
the shape of an egg, after seasoning, it may be served with mashed 
potato. 

Another Caudle (Ringer). — Mix well together one pint of cold 
gruel with a wineglassful each of good cream and sherry and a 
tablespoonful of noyau, and sweeten with sugar candy. 

Almond Cakes for Diabetics (See gen). — Take of blanched, sweet 
almonds a quarter of a pound, beat them as fine as possible in a 
stone mortar; remove the sugar contained in this meal by putting 
it into a linen bag and steeping it for a quarter of an hour in boiling 
water acidulated with vinegar ; mix this paste thoroughly with three 
ounces of butter and two eggs. Next add the yolks of three eggs 
and a little salt, and stir well for some time. Whip up the whites 
of three eggs and stir in. Put the dough thus obtained into greased 
moulds, and dry by a slow fire. 

Macaroni Boiled (U. S. Army Hospital Receipt for Twelve Men). 
— Macaroni, one pound ; salt, a quarter of an ounce ; boiling water, 
six pints. 

Directions. — Wipe the macaroni carefully. Break into four-inch 
lengths. Put with the salt into cold water and boil until tender, but 
not until it bursts or becomes a pulp. Drain off the water at once, 
and season with butter. The liquor from the macaroni makes a 
good broth. 

GELATIN PREPARATIONS 

Port-wine Jelly (Ringer). — Put into a jar one pint of port wine, 
two ounces of gum arabic, two ounces of isinglass, two ounces of 
powdered white sugar candy, a quarter of a nutmeg grated fine, 
and a small piece of cinnamon. Let this stand closely covered all 
night. The next day put the jar into boiling water and let it simmer 
until all is dissolved, then strain, let stand till cold, and then cut into 
small pieces for use. 

Milk, Rum, and Isinglass (Ringer). — Dissolve in a little hot water 
over the fire a pinch of the best isinglass ; let it cool, and mix a 
dessertspoonful of rum with it in a tumbler, and fill up the glass 
with new milk. 

Nutritious Coffee (Ringer). — Dissolve a little isinglass in water, 
then put half an ounce of freshly ground coffee into a saucepan with 
one pint of new milk, which should be nearly boiling before the 
coffee is added ; boil both together for three minutes ; clear it by 
pouring some of it into a cup and dashing it back again, add the 
isinglass, and leave it to settle on the hob for a few minutes. Beat 
up an egg in a breakfast cup, and pour the coffee upon it ; if pre- 
ferred, drink it without the egg. 

Lemon Jelly (U. S. Army Hospitals). — One fourth box of gelatin 
(one half ounce). One fourth cup of cold water. One fourth cup 



8 14 APPENDIX 

of fresh lemon juice (about the amount yielded by two lemons). 
Three tablespoonfuls of sugar. One and one fourth cups of boiling 
water. Put the gelatin to soak in the cold water, about twenty 
minutes being required for this process. When dissolved, pour on 
the boiling water. Add the lemon juice and sugar. Stir thoroughly 
and strain through a fine-meshed cloth into a china or granite-ware 
mould, cooling in a refrigerator or by placing in a pan of cold water. 
Never use tin moulds for lemon jelly. 

Coffee Jelly (U. S. Army Hospitals). — One fourth box of gela- 
tin (one half ounce). One fourth cup of cold water. One cup of 
boiling water. One half cup of strong coffee. Two tablespoonfuls 
of sugar. Soak the gelatin in the cold water for half an hour. Pour 
on the boiling water, then put in the sugar and coffee. Strain it 
through a cloth into a mould or dish in which it may be cooled, 
either in a pan of iced water or in a refrigerator. Coffee jelly may 
be served with cream and sugar. 

Have the coffee strong, two tablespoonfuls of coffee to each cup 
of water. Where vanilla extract is available, one half teaspoonful 
will be advantageously added to the above recipe. 

Wine Jelly (U. S. Army Hospitals). — One fourth box of gelatin 
(one half ounce). One fourth cup of cold water. One half cup of 
sugar. One half cup of sherry wine. One and one fourth cup of 
boiling water. One small piece of cinnamon. Put the gelatin and 
cold water together in a dish large enough to hold the whole mix- 
ture. Let it soak for half an hour, then pour the boiling water (in 
which the piece of cinnamon has been simmering) over the softened 
gelatin. Add the sugar and wine, strain through a clean cloth into a 
china or granite-ware mould, and cool in a refrigerator or a pan 
of cold water. 



INDEX 



Abnormal cravings, 328. 

Abnormalities of digestion, 349. 

Abscess of liver, 588. 

Absinthe, 252. 

Absorption of food, 358. 

Absorptive power of stomach, 521. 

Acid, hydrochloric, 517; lactic, 54; 
salicylic, in food, 281; salts, 518. 

Acids, 174; fatty, in cod-liver oil, 
200; in fruits, 174; vegetable, 48. 

Acidulous waters, 210. 

Acne, 616. 

Adams's dietary for young children, 
768. 

Addison's disease, 692. 

Adult life, food for, 307. 

Adulteration of cocoa, 223; of coffee, 
219; of food, 381; of liquors, 251; 
of milk, 61-63; of wines, 251. 

Aerated bread, 140. 

Age and food, 15, 284, 306. 

Albumin, 23; of egg, 102, 103; of 
milk, 54; vegetable, 349. 

Albuminoids, 349. 

Albuminuria, 492; functional, 493. 

Albumoses, 345, 349. 

Alcohol, 225; absorption, 232; action 
upon circulation, 229; action upon 
gastric digestion, 231; action upon 
mucous membranes, 231; action 
upon muscles, 230; action upon 
temperature, 230; and tuberculosis, 
460; antipyretic action, 236; as a 
diuretic, 231; as food, 9, 228; as a 
heart stimulant, 235; as a stimulant, 
229; as a tonic, 234; climate and, 
233; clinical uses, 234; consump- 
tion of, 239; elimination, 233; do- 
sage, 233; force value of, 226; in 
fevers, 236, 421-423, 431; in gout, 
650; hypodermic use, 233; in ner- 
vous diseases, 236; physiological 
action, 228; poisoning, 392; in ty- 
phoid fever, 431; value of, 225-228. 



Alcoholic beverages, 238. 

Alcoholism, 392. 

Ale, 241. 

Alimentary canal, 507; pastes, 152. 

Alkaline purges, 208. 

Allspice, 256. 

Almond cakes, 678; oil, 198. 

Almonds, 190. 

Alum and food, 281. 

Amphoper tones, 355. 

Amylaceous food, 812. 

Anaemia, 484; alcohol in, 237; bone 
marrow for, 196; pernicious, 489. 

Anaesthetics and food, 695. 

Analysis, chemical, of a man, 2; of 
liqueurs, 252; of milk, 58. 

Aneurism, 482; Tufnell's diet for, 483. 

Angina pectoris, 482. 

Angiocholitis, 584. 

Angostura, 252. 

Animal food, 4; force production 
and, 32; muscular labour and. 33; 
urea and, 32; vegetable and, com- 
pared, 29-35; viscera, 121. 

Anise, 252. 

" Anti-fat," 637. 

Antiseptic preservatives, 281. 

Apollinaris, 208. 

Apoplexy, 609. 

Appendicitis, 578. 

Appetite, 327, 397. 

Apple sauce, 181. 

Apples, 180. 

Apricots, 181. 

Arabs, diet of, 321. 

Arctic diet, 293-296, 318. 

Argol. 243. 

Army hospital dietaries, 793. 

Army prison dietaries, 713. 

Army ration, 14, 700; Austrian, 707. 
708; British, 707, 708; foreign, 707: 
French, 707, 709; German, 707, 709; 
Italian, 709; Russian, 709; Spanish, 
708; United States, 705. 
815 



8i6 



INDEX 



Aromatic herbs, 254. 
Arrack, 250. 
Arrowroot, 157, 809. 
Arterio-sclerosis, 482. 
Arthritis deformans, 640. 
Artichokes, 171; Jerusalem, 167. 
Artificial digestion, 352. 
Ascaris, 369. 
Ascites, 585. 
Asitia, 297. 
Asparagus, 172. 
Asses' milk, 58. 
Asthma, 470. 

Atheroma and vegetarianism, 36. 
Athletes, diet for, 727. 
Atwater's calorimeter, 10. 
Austrian army ration, 707. 

Bacillus acidi lactici, 67. 

Bacon, 120. 

Bacteria in diarrhceal stools, 556. 

Bacterium cyanogenum, 67. 

Bacterium synxanthum, 67. 

Baking, 268; powders, 139. 

Balfour's diet for senile heart, 480. 

Banana flour, 183, 184; meal, 183. 

Bananas, 182. 

Banting system, 626. 

Barley, 155; water, 155. 

Bauer's standard diet, 286. 

Bavarian beer, 241. 

Beans, 164; kidney, 164; red, 164; 
soy, 164; vanilla, 257. 

Beaujolais, 249. 

Beechnuts. 191. 

Beef, 109; blood, 112: broth, 116; 
chipped, no; concentrated, no; 
corned. 276; embalmed, 282; es- 
sence. 803; extracts, no, in, 802; 
fat, 196; jelly, in; juice, 114; meal, 
in; peptones, 117; peptonoids, 
113; powdered, 112; preparations, 
fluids, 801 ; preparations for the 
sick, no; preservation, 276; refrig- 
eration, 276; smoked, 275; tea, 114- 
116, 801, 802; tongue, 119. 

Beer, 239; brewing, 240; composi- 
tion of, 239. 

Beet, 167; sugar, 129. 

Bellevue Hospital dietaries, 781. 

Benger's food, 149; peptonised beef 
jelly, in. 

Beri-beri, 608. 

Berries, 186. 

Beverages, 205; demulcent, 799; diu- 
retic, 800; in fevers, 420; nutritive, 



799; receipts for, 799; refrigerant, 
800. 

Bicycle-racers' diet, 734. 

Bicycling and digestion, 337. 

Bile, 351. 

Biliousness, 366, 367, 580. 

Birds' nests, 123. 

Biscuits, 146; meat, 805; pilot, 151; 
ship, 151. 

Blackberries, 187. 

Blair's wheat food, 146. 

Blancmange, 809. 

Blood, 122; for rectal feeding, 409. 

Blueberries, 187. 

Boas's test, 517. 

Boat-crew dietary, 729, 731. 

Boiled beef, 261; fish, 263; milk, 75. 

Boiling, 261-263. 

Bone marrow, 196. 

Borax and food, 281. 

Bordeaux wine, 248. 

Boric acid and food, 281; in milk, 
63- 

Bottle feeding, 751. 

Bouchard's system, 635. 

Bouillon, 116, 804. 

Bourbon whisky, 250. 

Bovinine. 117. 

Boys' school diet, 773. 

Brain food, 330. 

Brains, 122. 

Brainworkers, diet for, 737-741. 

Braising, 269. 

Bran, 136; bread, 677. 

Brandy, 250. 

Brazil nuts, 191. 

Bread, aerated, 140; baking, 137; 
bran, 677; composition of, 137, 142; 
compressed, 271; dried, 271; dia- 
betic, 676; gluten, 145; Graham, 
144; inulin, 678; jelly, 150; making, 
135, I37-I4I; rice, 154; rye, 145; 
spoiled, 141; soya, 152, 679; stuffs, 
141; substitutes for, 675; whole 
meal, 143. 

Breast milk. See Human Milk, 55. 

Brie, 99. 

Bright's disease and milk, 73; acute, 
490; chronic, 496. 

British Army Hospital dietaries, 797. 

British army ration, 707. 

Broccoli, 170. 

Broiling, 264. 

Bronchitis, capillary, 469; chronic, 
470. 

Broncho-pneumonia, 474. 



INDEX 



8l 7 



Broth, chicken, 803; clam, 126; diet, 
779; mutton, 119; veal, 119. 

Broths, 803. 

Buckwheat, 152. 

Bulimia, 328, 526. 

Burgundy, 248. 

Butter, 96; adulterated, 96; analysis, 
96; cocoa, 198, 222. 

Butterine, 196. 

Buttermilk, 97, 682; cure, 97. 

Butternuts, 191. 

Cabbages, 169. 

Cacao butter, 198, 222. 

Calcium, 47. 

Calculi, biliary, 193; renal, 502; ves- 
ical, 502. 

Calorie, 12. 

Calories of carbohydrates, 12; of fats, 
12; of protein, 12. 

Calorimeter, 9. 

Calfs-foot jelly, 123. 

Camembert, 99. 

Cancer of the stomach, 550. 

Candy, 130, 774. 

Cane sugar, 129. 

Canning, 278-281. 

Capers, 256. 

Capillary bronchitis, 469. 

Capon, 121. 

Capsicum, 255. 

Caramel, 130. 

Carbohydrates, 19, 21. 

Carbon in food, 11, 16. 

Carbonic-acid gas in bread, 137; wa- 
ters, 208. 

Carcinoma of oesophagus, 509; of 
stomach, 550. 

Carnrick's food, 150; soluble food, 92. 

Caroid, 358. 

Carrots, 168. 

Casein, 54; vegetable, 163, 349. 

Cassava, 157. 

Catsup, 257. 

Caudle, 813. 

Cauliflower, 170. 

Caviare, 125, 311. 

Cayenne pepper, 255. 

Celery, 171. 

Cellulose, 13. 

Centrifugal cream, 95. 

Cepe, 189. 

Cereals, 133. 

Cerebro-spinal meningitis, 444. 

Certified milk, 68. 

Cetraria, 158. 



Chalybeate waters, 210. 

Chambers's system, '636. 

Champagne, 247; Chartreuse, 252. 

Cheddar, 100. 

Cheese, 97; Brie, 99; Camembert, 
99; cream, 98; Roquefort, 99; 
Gorgonzola, 100; poisoning, 377. 

Chervil, 171. 

Chestnuts, 191. 

Chicken, 121; broth, 803; jelly, 805. 

Chicory, 171, 219. 

Childhood and food, 306. 

Children, dietaries for, 761-768; 
starchy foods for, 158. 

Children's hospital dietaries, 793. 

Chilies, 255. 

Chloride of sodium, 45. 

Chlorosis, 484. 

Chocolate, 223; habit, 223; prepara- 
tion, 223. 

Cholera, 446. 

Cholera infantum, 558; infection and 
food, 388; morbus, 560. 

Chorea, 606. 

Cider, 253. 

Circulation and diabetes, 661 ; and di- 
gestion, 332. 

Circulatory system, 476. 

Cirrhosis, 584. 

Clams, 126. 

Claret, 244, 248. 

Classes of foods, 37. 

Climate and alcohol, 2^3', and food, 
284, 320. 

Clothing and food, 284. 

Clotted cream, 95. 

Clouty cream, 67. 

Cocoa, 221; adulteration of, 223; 
composition of, 221. 

Cocoanut oil, 198. 

Cocoanuts, 191. 

Codfish, 125. 

Cod-liver oil, 199, 459; dosage, 200; 
inunctions, 204; methods of ad- 
ministration, 201; properties, 199; 
substitutes for, 203; uses, 203; tu- 
berculosis and, 459. 

Coefficiency of foods, 25. 

Coffee, 215; adulteration of, 219; and 
tea compared, 220; composition of, 
215; habit, 218; ill effects of, 218; 
physiological action of, 217; prep- 
aration of, 216; substitutes for, 220. 

Cognac, 250. 

Cole, 170. 

Colitis, chronic, 561. 



8i8 



INDEX 



Colostrum, 64; human, 57. 
Commercial life, diet in, 741. 
Concentrated food, 270. 
Condensed cream, 95; food, 270; 

milk, 93. 
Condiments, 253. 
Confectionery, 130, 774. 
Consomme, 804. 

Constipation, chronic, 568; in chil- 
dren, 576; in infants, 576; fruits for, 

177. 
Convalescence, diet in, 423, 799; in 

typhoid fever, 434. 
Cook County Hospital dietaries, 788. 
Cooking, 259; varieties of, 260. 
Corn, 153. 
Cornaro's diet, 299. 
Cornmeal, 154. 
Cornstarch, 154. 
Corpulency, 621. 
Cost of foods, 26-28, 319. 
Cottolene, 196. 
Cottonseed oil, 198. 
Crabs, 125. 
Crackers, 142, 151. 
Cranberries, 173. 
Cream, 52, 94; centrifugal, 95; cheese, 

98; clotted, 95; condensed, 95; 

Devonshire, 95; estimation of, 60; 

evaporated, 95; ice, 96; poisoning 

by, 377; separator, 95. 
Cream-of-tartar drink, 800. 
Creamometer, 60. 
Cress, 170. 
Crimping, 125. 
Crustaceans, 125. 
Crystalose, 679. 
Cucumbers, 171. 
Cuisine, 196. 
Curagoa, 252. 
Cure, buttermilk, 97; dry, 726; fruit, 

723; grape, 185, 724; koumiss, 82; 

milk, 51, 719; rest, 600; whey, 101, 

721. 
Currants, 187; dried, 178. 
Curry, 253. 
Custard, 105. 

Dahi, 388. 

Dandelion roots, 170. 
Darby's fluid meat, 112. 
Dates, 188. 

Decorticated flour, 145. 
Delirium tremens, 395. 
De Long expedition, 293. 
Dementia, 610. 



Demulcent beverages, 799. 

Dentition, 507. 

Dermatitis exfoliative, 620. 

Desiccation, 270. 

Deutero-albumose, 349. 

Devonshire cream, 95. 

Dextrin, 127. 

Diabetes mellitus, 654; beverages in, 
680; and circulation, 661; course, 
666; diagnosis of, 667; dietetic 
treatment, 668-684; During's diet, 
683; Ebstein's diet, 682; gout and, 
656; hygienic treatment, 684; na- 
ture of, 654; and nervous system, 
661; Naunyn's diet, 683; and other 
diseases, 656; and pancreas, 660; 
physiological experiments, 657; 
prognosis, 667; prophylaxis, 668; 
substitutes for sugar in, 679; 
skimmed milk in, 682; symptoms 
of, 663; theories of, 661. 

Diabetic diets, 682; urine, 663. 

Diabetin, 679. 

Diarrhoea, 552; chronic, in children, 
554, 563; in infants, 554; summer, 
557- 

Diastase, 148, 159. 

Diathesis, gouty, 647. 

Diet, alimentary-canal diseases and, 
507; anaesthetics and, 695; arctic 
expedition, 293-296; for athletes, 
727; for brainworkers, 737-741; 
average daily, for adult, 288; in 
commercial life, 741 ; of concen- 
trated foods, 272; in convalescence, 
423; Cornaro's, 299; in disease, 415; 
in fever, 415; in infectious disease, 
415; of football team, 26; improp- 
erly balanced, 304; kitchen outfit, 
414; leanness and, 638; and lapa- 
rotomy, 698; liver diseases and, 580; 
milk, 49; mixed, 33; nervous dis- 
eases and, 591; and occupation, 
734; in pregnancy, 744; in prisons, 
712; in puerperal women, 744; race 
and, 314; for school-children, 769- 
776; respiratory system, diseases in, 
467; of soldiers, 26; for starvation, 
297, 298; surgical patients, 695; in 
travel, 743; Tufnell's, 483; urinary 
system diseases and, 489; variety 
in, 329; vegetarian, 35. 

Dietaries, standard, 15, 287. 

Dietetic complications in associated 
diseases, 694. 

Diets, diabetic, 682. 



INDEX 



819 



Digestibility of foods, 25; compara- 
tive, of meats, 109; of nutrients, 25. 

Digestion, 323; alcohol and gastric, 
231; artificial, 352; abnormalities 
of, 349; circulation and, 332; dura- 
tion of, 346-348; exercise and, 336; 
external heat and, 333; of fats, 351; 
in the intestine, 350; mental emo- 
tion and, 340; in the mouth, 340; 
and nervous system, 331; and rest, 
337; in the stomach, 341; salivary, 
341; and temperature, 333; sleep 
and rest and, 337; and wines, 249. 

Digestive ferments, 353. 

Dilatation of the stomach, 536; lav- 
age, 535- 

Diphtheria, 442; feeding in, 339; and 
milk, 66, 390; paralysis in, 444. 

Diseases due to dietetic errors, 365; 
especially influenced by diet, 621; 
miscellaneous, 692. 

Disinfection of utensils, 401. 

Distilled water, 40. 

Diuretic beverages, 800. 

Donkin's diet for diabetics, 682. 

Dough, 137. 

Doura, 153. 

Dried dates, 178; fruits, 178; vege- 
tables, 271. 

Drinks, effervescing, 207. 

Drugs in human milk, 57. 

Dry cure, 726; Tufnell's, 483. 

Drying of food, 270. 

Duck, 121. 

Dujardin-Beaumetz system, 634. 

Diiring's diabetic diet, 683. 

Dysentery, 566; chronic, 567. 

Dyspepsia, 511, 521-527; alcohol in, 
238; atonic, 526; dietetic treatment 
of, 521; in children, 526; flatulent, 
525; foods forbidden in all cases, 
521; foods allowable, 522; gout and, 
526; hyperacidity, 527; irritation, 
526; nervous, 526. 

Dyspeptics, rules for, 525. 

Dysphagia, 508. 

Ebstein diabetic diet, 682; system, 

626. 
Economic value of food, 24. 
Eczema, 616. 
Eczema, in children, 619; in infants, 

619. 
Eels, 124. 

Egg albumin, 102; preparations, 807. 
Eggnog, 103, 807. 



Egg plant, 171. 

Eggs, 101; boiled, 104; cooked, 104; 
composition of, 101 ; desiccated, 
106; dried, 271; evaporated, 106; in 
fever, 419; plover's, 197; preserva- 
tion of, 105; preserved, 278; raw, 
103; for rectal feeding, 409; tuber- 
culosis and, 458. 

Elements, chemical, 1 ; quantity of, 
in standard diets, 19. 

Elimination of food, 359. 

Embalmed beef, 282. 

Embryomine, 677. 

Emergency ration, 706. 

Emphysema, 471. 

Empyema, 476. 

Enemata, milk, 70; nutrient, 403. 

Energy from foods, 7; and foot tons, 
18; potential, in foods, 26. 

English walnuts, 190. 

Enteralgia, 591, 595. 

Enteritis, acute catarrhal, 560; chron- 
ic, 561 ; membranous, 565. 

Entero-colitis, 557; chronic, 563. 

Epilepsy, 583. 

Equivalents, food, 285. 

Erbswurst, 163. 

Ergotism, 380. 

Erysipelas, 445. 

Erythema, 615. 

Eskay's albuminised food, 150; food, 
114. 

Eskimo diet, 315-318. 

Ewald's test breakfast, 515. 

Exercise, digestion and, 336; food 
and, 15, 284, 336. 

Exophthalmic goitre, 693. 

Extracts, 270; of beef, 113; of pan- 
creas, 79, 356. 

Extractum carnis, 116. 

Famine, 304. 

Farina, 150; gruels, 429. 

Farinaceous diet in hospitals, 777; 

foods, 146, 809. 
Fasting, 298. 
Fat of milk, 52; beef, 196; diarrhoeal 

stools and, 555; of pork, 196. 
Fats, 19, 192; animal, 195; dietetic 

uses of, 198; digestibility of, 194; 

digestion of, 351; tuberculosis and, 

459; uses of, 192; vegetable, 197. 
Feces and food, 12. 
Feeding, forced, 465, 610; of helpless 

patients, 400; hypodermic, 411; of 

infants, 749; intravascular, 411; rec- 



820 



INDEX 



tal, 403, 408; the sick, 397; of un- 
conscious patients, 402; young chil- 
dren, 764. 

Ferments, 353; in foods, 274. 

Fever, alcohol in, 236, 421-423, 431 ; 
beverages in, 420; diet in, 415; di- 
etetic treatment of, 417-420; pathol- 
ogy of, 415; remittent, 453; thirst 
in, 430; typhoid, 425; typhus, 437. 

Figs, 188. 

Fig wine, 251. 

Filbert, 172. 

Filtered water, 40. 

Finkler's proteid feed, 112. 

Fish, 124; cooking of, 269; desic- 
cated, 125; diet, 778; digestibility 
of, 125; fat, 197; oils, 197; poison- 
ing by, 378; smoked, 275. 

Fistula, gastric, 510. 

Flatulency, 525. 

Flaxseed tea, 800. 

Flies and food infection, 390. 

Flour, 133; ball, 147; banana, 183; 
decorticated, 145; wheaten, 142. 

Food, absorption, 358; age and, 15, 
284, 306; adulteration, 381; anaes- 
thetics and, 675; animal, 4, 48; an- 
tiseptics and, 281; body weight and, 
312; canned, 278-281; carbon in, 
16; childhood and, 306; cholera in- 
fection and, 388; classes of, 37; cli- 
mate and, 284; clothing and, 284; 
combustion, 9, 12; "complete," 4; 
composition of, 3, 4, 6; concen- 
trated, 272; concentration, 270; 
condensed, 270; cost of, 26-28; 
desiccation of, 270; digestion, 323; 
digestibility of, 25; dried, 270, 274; 
economic value of, 24; elementary 
composition of, 1; elimination of, 
359; enemata, 408-412; energy 
from, 7; equivalents, 285, 361; ex- 
ercise and, 15, 284, 336; extracts, 
270; farinaceous, 146; force pro- 
ducing, 7, 18, 28; frozen, 276; fuels, 
9; heat-producing, 8; heredity and, 
314; hydrogen in, 16; idiosyncrasy 
and, 391; infants', 146, 748; malted, 
354; medicines and, 411-414; mi- 
cro-organisms, 385; nitrogen in, 16, 
20; nitrogenous, 5; non-nitrogen- 
ous, 5; nutrition percentage of, 25; 
in old age, 308; oxygen in, 16; 
parasites and, 368; poisoning, 375; 
potential energy in, 26; prepara- 
tion, 259; preservation, 259, 274; 



ptomaines and, 374; purveyors, 414; 
quantity of, 398; quantity required, 
28, 283; race and, 314; refrigera- 
tion, 276; relative to special dis- 
eases, 363; respiration, 16; respira- 
tory, 5; salted, 275; sex and, 285, 
313; starchy, 133; serving the sick, 
398; size of body and, 311; sleep 
and, 430; special conditions for, 
306; sterilisation, 277; stimulating, 
23; substitutes for, 282; supposi- 
tories, 410; temperature and, 284, 
333S36', tobacco and, 360; typhoid 
infection, 388; urine and, 360, 489; 
vegetable, 5, 160; vegetable and 
animal, compared, 29-35; work 
and, 15; for young children, 761. 

Foot-and-mouth disease, 390; and 
milk, 65. 

Football dietary, 733. 

Foot pounds and work, 12. 

Foot tons and food energy, 18. 

Forced feeding, 465, 610. 

Force-producing value of foods, 18. 

Force production, 7. 

Foreign bodies swallowed, 510. 

Formaldehyde and food, 281, 282; in 
milk, 63. 

Fowl, 121. 

French Army Hospital dietaries, 798. 

Frijole, 164. 

Fromentine, 677. 

Fruit in constipation, 572; cures, 723; 
poisoning, 177; sirups, 208; soups, 
178. 

Fruits, 174; composition of, 175; dia- 
betes in, 674; digestibility of, 178; 
dried, 178; ripening, 177; uses and 
properties, 176; varieties, 179. 

Frying, 267. 

Fuel value, 9, 12; of foods, 28. 

Functional albuminuria, 493. 

Fungi, 188; in milk, 67. 

Furunculosis, 621. 

Fusel oil, 250, 252. 

Gaduin, 200. 

Gaertner's Mother Milk, 93. 

Gall ducts, 584. 

Gallstones, 588. 

Game, 121; high, 267; poisoning, 

375- 
Garlic, 172. 
Garrison ration, 705. 
Gases of stomach, 512. 
Gastralgia, 591, 594. 



INDEX 



821 



Gastrectasia, 536. 

Gastric catarrh, acute, 527; chronic, 
530; in children, 536. 

Gastric digestion, 341; juice, 342; 
total acidity of, 516; fever in chil- 
dren, 529. 

Gastritis, acute, 527; chronic, 530. 

Gastro-intestinal catarrh, chronic, 

563. 

Gavage, 754. 

Gelatin, 122, 349; preparations of, 
814. 

Gerber's food, 149. 

Germain See system, 632. 

German army ration, 707. 

Germs in food, 274, 282. 

Gin, 251. 

Ginger, 256; ale, 208. 

Glucose, 132. 

Gluten, 136; bread, 145, 676; flour, 
676; vegetable, 161. 

Glutenin, 136. 

Gluttony, 366. 

Glycerin, 199. 

Glycogen, 23. 

Goat's milk, 57. 

Goitre, exophthalmic, 693. 

Gonorrhoea, 506. 

Goose, 121, 

Gooseberries, 187. 

Gorgonzola, 100. 

Gout, 641; alcohol in, 650; chronic, 
647; saline waters in, 653. 

Gouty diathesis, 647. 

Graham bread, 144. 

Grain poisoning, 379, 380. 

Granola, 151. 

Granose, 151. 

Granum, 147. 

Grape cure, 724; " food," 185. 

Grapes, 184. 

Gravel, 504. 

Greengages, 185; tea, 211; vegeta- 
bles, 161. 

Greens, 161, 170. 

Grilling, 264-267. 

Groats, Scotch, 156. 

Grocer's itch, 130. 

Grog de la poudre de viande, 112. 

Ground pear, 167. 

Grouse, 121. 

Gruels, 809-811; farinaceous, 429. 

Gruyere, 99. 

Guinea-worm disease, 369. 

Gum in fruits, 175. 

Giinzberg's test, 517. 



Haemoptysis, 468. 

Haemorrhage of lungs, 468. 

Haemorrhoids, 578. 

Ham, 120. 

Hard labour prison diet, 284. 

Hard-tack, 151. 

Haricots, 164. 

Harvard boat crew dietary, 731. 

Hasheesh and fasting, 283. 

Heart, 122; diseases of, 476; senile, 

479- 
Heat, external, and digestion, 333. 
Heat-producing foods, 8. 
Heat unit. See Calorie, 12, 15. 
Herb teas, 207. 
Heredity and food, 314. 
Hetero-albumose, 349. 
Hindu, diet of the, 320. 
Hock, 249. 

Hoff's malt extract, 160. 
Holt's table for infant feeding, 757. 
Honey, 132. 
Horlick's food, 148. 
Horseflesh, 120. 
Horseradish, 258. 
Hospital dietaries, 776. 
Hot-water cure and meat, 726. 
Hours for meals, 323-327. 
House diet, 777. 
Huckleberries, 187. 
Humanised milk, 88. 
Human milk, 55; artificial, 88; drugs 

in, 57- 
Hunger, 302, 339, 404. 
Hydrochloric acid, 343, 517; gastritis 

and, 535. 
Hydrogen in food, 16. 
Hyperacidity, 349, 525. 
Hypersecretion, 349, 519. 
Hypodermic feeding, 411. 

Ice, 45. 

Ice cream, 96; poisoning by, 377. 

Iced fluids, 334. 

Iceland moss, 190, 158. 

Idiosyncrasy and food, 391. 

Imperial Granum, 147. 

Inanition, 297. 

Indian meal, 154. 

Indigestion, 511. 

Infancy food required, 757. 

Infant foods, 146, 748; artificial, 759. 

Infantile scurvy, 690. 

Infants, premature, 761. 

Infectious diseases, diet in, 415. 

Influenza, 440. 



822 



INDEX 



Insanity, acute, 610; dietaries, 791. 

Insomnia, 605. 

Intermittent fevers, 453. 

Intestinal antisepsis, 432; gases, 352; 
digestion in children, 562; obstruc- 
tion, acute, 567; putrefaction, 560; 
worms, 369. . 

Intravascular feeding, 411. 

Intubation, 442. 

Inulin biscuit, 678. 

Inunction foods, 410. 

Iron, 48. 

" Iron ration," 164. 

Isinglass, 122. 

Italian pastes, 152. 

Jam, 187. 

Jaundice, 584. 

Jellies, 123. 

Jelly, 812, 813, 814. 

Jerusalem artichoke, 167. 

Jockey's diet, 734. 

Johannis water, 208. 

Johns Hopkins Hospital dietaries, 

787. 
Johnson's fluid beef, 116. 
Junket, 806. 

Kava, 225. 

Keating's diet, 603. 

Kefir, 83. 

Kepler's extract of malt, 160. 

Kidney beans, 164. 

Kidneys, 122. 

Kindermilch, 357. 

Kirsch, 250. 

Kneipp system, 723. 

Kohl rabi, 168. 

Kola, 224. 

Koumiss, 80, 807; composition of, 

81; cure, 82; properties of, 81. 
Koumys. See Koumiss. 
Koumysgen, 82. 
Kummel, 252. 
Kumyss. See Koumiss. 

Laboratories, milk, 88. 
Lactalbumin, 54. 
Lactated food, 92, 149. 
Lactic acid, 54. 
Lactometer, 59. 
Lactone, 83. 
Lacto-preparata, 92. 
Lactose, 53, 132. 
Lamb, 119. 
Laparotomy and diet, 698. 



Lard, 195. 

Laryngismus stridulus, 467. 

Laryngitis, tubercular, 468. 

Lathyrism, 380. 

Lavage, 535, 538. 

Lead poisoning, 384, 693; and milk, 
70. 

Leanness, 638. 

Leaven, 138. 

Lebert's milk cure, 463. 

Leeks, 172. 

Legumes, 162. 

Legumin, 80, 6jJ. 

Lemonade, 179, 207, 800; efferves- 
cing, 800; in fever, 420; substitutes 
for, 207. 

Lemons, 179. 

Lentils, 165. 

Lettuce, 170. 

Levulose, 132. 

Leyden's diet, 603. 

Lichen, 190. 

Liebig's extract of meat, 116; foods, 
148. 

Lima beans, 164. 

Lime, 46, 47; saccharated, 78; water, 
807; juice, 179; biscuit, 46. 

Limes, 179. 

Linseed oil, 198. 

Lipanin, 203. 

Liqueurs, 252. 

Liquor, consumption of, 239; adul- 
teration of, 251; malt, 239; thera- 
peutic uses of, 251. 

Liquors, 250. 

Liver, 122; abscess of, 588; amyloid, 
587; diseases, diet in, 580; fatty, 
586. 

Liverpool Infirmary dietaries, 787. 

Lithsemia, 504. 

Lobsters, 125. 

Locomotor ataxia, 608. 

Loeflund's cream emulsion, 149; malt 
extract, 160. 

Macaroni, 152. 

Macaroons, 190. 

Mace, 256. 

Madeira, 252. 

Maize, 153. 

Malaga, 246. 

Malaria, 453. 

Malmsey, 246. 

Malt, 240; extracts, 159; liquors, 239. 

Malted milk, 92, 149. 

Maltine, 160. 



INDEX 



823 



Maltose, 132, 159, 353. 

Mangoes, 181. 

Mania, 610. 

Manioc, 157. 

Mannite, 132. 

Maple sugar, 129. 

Marasmus, 564. 

Mare's milk, 58. 

Marrow, bone, 196; vegetable, 173. 

Mash, sour, 250. 

Massage, constipation in, 574; of 
stomach, 541. 

Mate, 220. 

Matzoon, 83. 

Meal, banana, 183; corn, 154; Indian, 
153; pea, 164; peanut, 165. 

" Measles," 370. 

Measles, 439. 

Meat, 106; composition of, 107; con- 
sumption of, 106; digestibility of, 
108; dried, 271; extracts, composi- 
tion of, 118; frozen, 276; hot-water 
cure and, 726; lozenges, 113; poi- 
soning, 375; preparations, fluid, 
117; solid, 804; preservation, 281; 
raw, 108; quantity eaten, 106; 
smoked, 275; sterilised, 277; tu- 
berculosis and, 386, 457. 

Mechanics, diet of, 28, 29. 

Medicines and food, 411-414. 

Melancholia, 610. 

Mellin's food, 148. 

Melons, 187. 

Meningitis, cerebro-spinal, 444. 

Mental emotion and digestion, 340. 

Metabolism, 9. 

Meteil, 153. 

Micro-organisms and food, 385. 

Migraine, 595. 

Milk, 48-93; absorbent power of, 67; 
adaptation of, for the sick, 72,; 
adulteration, 61-63; albumin of, 54; 
albuminoid, 61; alkalies with, 77; 
amylaceous foods, 77; analysis, 52, 
58; analysis of human, 55, 60; arti- 
ficial human, 753; asses', 58; bac- 
teria in, 66, 67, 87; boiled, 75; bot- 
tles, 87; chemical composition of, 
52; contamination, 63; colour of, 
58, 63; cure, 51, 719; Lebert's, 463; 
diet, 49; Bright's disease in, 497; 
gastritis, 532; diet in tuberculosis, 
463; digestion, 71; dilution of, 76; 
diphtheria and, 66, 390; derivatives, 
93; dried, 270; enemata, 70; fat, 52; 
fat, estimation of, 60; improving 
54 



the digestibility of, 75; impurities, 
61; indigestion, 72; infant feeding, 
and, 751; infection, 64, 68, 385; 
acute, 558; "foods," 92; foot-and- 
mouth disease and, 65; fever in, 
417; gelatin and, 78; goat's, 57 
human, 55; human drugs in, 57 
humanised, 88; laboratories, 88 
lead poisoning, 70; legal stand- 
ards of, 62; malted, 149; methods 
of altering the taste of, 74; modi- 
fied, 88, 92; odour, 58; other foods 
compared and, 53; pancreatinised, 
79; pasteurised, 86; peptonised, 78; 
poisoning by, 377; predigestion of, 
78; preparations, 806; prescrip- 
tions, 89-91; preservation, 84; re- 
action, 58; scalded, 76; scarlatina 
and, 66, 390; skimmed, 75; 
skimmed, in diabetes, 682; steril- 
ised, 84; substitutes for, 428, 753; 
total solids, 59; tuberculosis and, 
64, 386; typhoid fever and, 66, 426; 
uses of, 69; varieties of, 54. 

Millet, 153. 

Mineral waters, 207. 

Mint, 171, 258. 

Molasses, 131. 

Morel, 189. 

Mosquera's beef jelly, in; beef meal, 
in. 

Mother Milk, 93. 

Moulds in cheese, 100. 

Mouth, cleansing of, 401 ; care of, 

433- 
Mucous diarrhoea, 565. 
Mulberries, 187. 
Mulled wine, 801. 
Mumps, 440. 
Muscarin, 189. 
Mush, 154. 
Mushrooms, 188. 
Muskmelon, 187. 
Mussels, 126. 
" Must " of wines, 245. 
Mustard, 255. 
Mutton, 119. 
Mytilotoxin, 378. 

Naunyn's diabetic diet, 683. 

Navy rations, 710. 

Nectarines, 181. 

Negro diets, 319. 

Nephritis, acute, 490; in children, 

492; chronic, 496. 
Nervous diseases, alcohol in, 236. 



824 



INDEX 



Nervous system, 591; diabetes and, 
661; digestion and, 331. 

Nestle's food. 150; milk food, 92. 

Neuchatel, 100. 

Neuralgia, 591. 

Neurasthenia, 597. 

Neutrose, 100. 

New York Hospital dietaries, 779. 

New York Infirmary for Women and 
Children, 788-791. 

New York State Reformatory diet- 
ary, 716-718. 

Nitrogen balance, 20; in food, 11, 16, 
20; lag, 21. 

North Eastern Hospital for Children, 

793- 
Nursing bottles, 760; mother. 747. 
Nut flour, 678. 
Nutmeg. 256. 
Nutrient enemata, 403. 
Nutrition, 29; percentage of foods, 

25- 
Nuts, 190; in diabetes, 674; in consti- 
pation. 573. 

Oatmeal. 155. 

Oats. 155. 

Obesity, 621. 

Occupations and diet, 734. 

Oertel system, 628-632. 

(Esophagus, carcinoma of, 509; stric- 
ture of, 509. 

Oidium lactis, 67. 

Oil, almond, 198; cod-liver, 199; cot- 
ton-seed, 198; linseed, 198; olive, 
197; peanut, 198; theobroma. 198. 

Oils, 192; vegetable, 197. 

Okra, 171. 

Oleomargarine, 196. 

Olive oil and biliary calculi, 193; in- 
unction, 193. 

Olives, 186. 

Omelette, 105. 

Onions, 172. 

Operations and diet, 696. 

Orangeade, 180. 

Oranges, 180. 

Osteomalacia. 692. 

Overdrinking, 367. 

Overeating, 366. 

Overfeeding, 778. 

Oxaluria, 501. 

Oxygen in food. 16. 

Oyster plant, 168. 

Oysters, 126; typhoid fever and, 
388. 



Palpitation, 482. 

Panada, 812. 

Pancreas, diabetes and, 660; diseases 
of the, 591. 

Pancreatic extract of malt, 160. 

Pancreatin, 356. 

Pancreatinised meat for rectal feed- 
ing, 408; milk, 79. 

Panopeptone. 118. 

Papoid. 357. 

Paralysis, post-diphtheritic, 444; and 
food, 368. 

Parsley, 171. 

Parsnips, 168. 

Pasteurised milk, 86. 

Pastry, 146. 

Peaches, 181. 

Pea meal. 164; soup. 164. 

Peanut oil, 198. 

Peanuts, 165. 

Pearl tapioca, 157. 

Pears, 181. 

Peas, 162. 

Pea soup, 164. 

Pecan nuts, 191. 

Pectin, 174. 

Pellagra, 381. 

Pemmican, 196, 271, 293. 

Pepper, cayenne. 255; black, 255; 
white, 255. 

Peppermint, 255. 

Pepsin, 344, 354. 519- 

Peptic ulcer, 546. 

Peptones, 345, 349, 355- 

Peptonoids. 113. 

Peptonised milk, 78. 

Peristalsis, 346. 

Peritonitis, acute, 579; chronic, 
580. 

Pernicious anaemia, 489. 

Pertussis, 440. 

Phosphates. 47. 48. 

Phosphorus. 48. 

Phthisis, 456. 

Pickles, 257, 281. 

Pie plant, 172. 

Pigeon, 121. 

Pigments in food, 383. 

Pilot biscuits, 151. 

Pineapples, 181. 

Pistachio, 191. 

Plasmon. 100. 

Playfair's diet, 602. 

Pleurisy, 474. 

Plums, 185. 

Pneumonia, 472. 



INDEX 



825 



Poisoning, alcohol, 392; by cheese, 
377', by cream, 378; by fish, 378; 
by fungi, 189; by grain, 380; by ice 
cream, 377; by lead, 384, 693; by 
meat, 375; by milk, 377; by shell- 
fish, 378; by tin, 384. 

Poland water, 208. 

Polenta, 154. 

Poluboskos, 145, 677. 

Polysarcia, 621. 

Pomegranate, 181. 

Pomelo, 180. 

Pork, 120, 196. 

Porridge, 812. 

Porter, 241. 

Port wine, 245, 252. 

Potassium salts, 47. 

Potatoes, 165; sweet, 167. 

Pot cheese, 99. 

Powder, baking, 139. 

Predigestion of milk, 78; of proteids, 
354; of starch, 353. 

Pregnancy, diet in, 744; vomiting of, 

543- 
Premature infants, 761. 
Presbyterian Hospital dietaries, 781- 

784. 

Prisons, diet in, 712. 

Professional men's diet, 325. 

Proprietary foods, 759. 

Proteids, 7, 19; digestion of, 348; pre- 
digestion of, 354; vegetable, 161. 

Protein, 7; daily income and outgo 
of, 11; required per diem, 13. 

Proteoses, 349. 

Protogen, 104. 

Prunelles, 186. 

Prunes, 186. 

Pruritus, 621. 

Prussian Army Hospital dietaries, 
798. 

Psoriasis, 620. 

Ptomaines and food, 374. 

Ptyalin, 341. 

Puddings, 146. 

Puerperal women, diet for, 744. 

Pugilists' diet, 734. 

Pulled bread, 150. 

Pulmonary haemorrhage, 468. 

Pulque, 205. 

Pumpernickel, 144. 

Pumpkin, 172. 

Purees, 418. 

Purpura, 692. 

Purveyors of food, 414. 

Pyaemia, 452. 



Pyelitis, 501. 
Pyrosis, 349. 

Quantity of food, 398; for children, 

757- 
Quinces, 181. 
Quinsy, 508. 

Rabbit, 121. 

Rabies, 454. 

Race and food, 314. 

Radishes, 168. 

Rain water, 39. 

Raisin wine, 249. 

Raisins, 185. 

Raspberries, 187. 

Ration, bare sustenance, 17; emer- 
gency, 706; garrison, 14, 705; ideal, 
17; liquid, 287; solid, 287; work, 17. 

Rations, 700; army, 14, 700; navy, 
710. 

Raw meat, 804. 

Receipts for invalid foods, 799. 

Rectal feeding, 403-408. 

Rectum, care of, 406. 

Refrigeration, 276. 

Reindeer milk. 58. 

Rennet ferment, 519. 

Rennin, 71. 

Respiration and food, 16. 

Respiratory foods, 5; system, 467. 

Rest cure, 600; digestion and, 337. 

Revalenta, 157, 165. 

Rhachitis, 685. 

Rheumatism, acute, 639; chronic, 
640. 

Rhine wines, 246. 

Rhubarb, 172. 

Rice, 154; flour, 140. 

Rickets, 685. 

Ridge's food, 146. 

Riegel and Leube's test dinner, 515. 

River water, 40. 

Roasting, 264. . 

Robinson's patent barley. 146. 

Roe, 125. 

Roosevelt Hospital dietaries, 786. 

Root beer, 207. 

Roots, 165. 

Roquefort. 99. 

Rosacea. 620. 

Rotch's modified milk, 88; table for 
infant feeding, 757. 

Roundworm, 369. 

Rubeola, 439. 

Rudisch's beef peptone, 113. 



826 



INDEX 



Rum, 251. 

Rye, 153; bread, 145; whisky, 250. 

Saccharin, 133, 679. 

Saccharose. 128. 

Sago, 158. 

Sake, 250. 

Salcify, 168. 

Salep, 157. 

Salicylic acid, food in, 384: milk in, 

63. 

Saline waters in gout, 653. 

Saliva, 341. 

Salmon, 124. 

Salt, celery, 171 ; habit. 46. 

Salts, 18, 45; calcium, 47; deprivation, 
46; excess of, 45; potassium, 47; 
sodium, 46, 47; uses of, 45; vari- 
eties of, 45. 

Samp, 154. 

Sanose, 100. 

Sarcopeptone, 113. 

Sauces, 257. 

Sauerkraut, 170. 

Savory & Moore's Infant Food, 148. 

Scalded milk, 76. 

Scarlatina and milk, 66. 390. 

Scarlet fever, 438. 

Schleicher's diet, 632. 

School children, diet for, 769-776. 

Schroth's method, 727. 

Schumacher's food, 146. 

Schweniger system. 632. 

Sclerosis, 482. 

Scotch groats, 156. 

Scraped beef, 805: meat, m. 

Scurvy, 48, 688; in infants. 690. 

Seakale, 170. 

Seasickness, 544. 

Season and food, 320. 

Seegen's almond flour. 678. 

Seltzer, 208. 

Semolino, 151. 

Senile heart, 479. 

Separated cream, 95. 

Septicaemia, 452. 

Sex and food, 285. 313. 

Shaddocks, 180. 

Shallots, 172. 

Shellfish, 126; poisoning by, 378. 

Sherry, 246, 252. 

Ship biscuits, 151. 

Shredded wheat, 150. 

Shrimp, 125. 

Shrub, 187. 

Sirup, 131; maple, 129. 



Skimmed milk, 75. 

Skin diseases, 614. 

Sleep, digestion and, 338; feeding 
and, 401, 769; food and, 430. 

Smallpox, 438. 

Smalt, 96. 

Smoking, 275. 

Soda water, 208. 

Sodium, 45; chloride, 46. 

Soldier's diet, 26. 

Somatose, 113. 

Sorghum, 130. 

Sorrel, 170. 

Soups, 268, 803; fruit, 178. 

Sour mash, 250. 

Soused fish, 281. 

South American beef extract, 113. 

Soya, bean, 164; bread, 152. 

Spaghetti, 152. 

Spices, 253, 256. 

Spinach, 170. 

Spirits, 252. 

Squab, 121. 

Squash, 172. 

Standard dietaries, 15, 286. 

Standards of digestibility of foods, 
25- 

Starch in vegetable foods, 135. 

Starches, predigestion of, 353. 

Starchy foods, 133; for children, 
158. 

Starr's table for infant feeding, 757. 

Starvation. 297; symptoms, 300; 
treatment, 303. 

Steaks, 266. 

Steaming. 268. 

Stearin, 196. 

Sterilised milk, 84. 

Stewing, 263. 

Stilton, 100. 

Stimulants, 205. 

Stimulating foods, 23. 

Stomach, absorption, 521 ; cancer of, 
550; digestion in, 341; dilatation of, 
536: acute catarrh of, 527; chronic 
catarrh of, 530; examination of 
contents, 515; motility, 520; ulcer 
of, 546. 

Stomatitis, catarrhal, 507. 

Stools, examinations of, 555; of in- 
fants. 759- 

Stout, 241. 

Strawberries, 186. 

Stricture of oesophagus, 509. 

Strippings. 54. 

Substitutes for foods, 282. 



INDEX 



82/ 



Sucrose, 129. 

Suet, 196. 

Sugar, 22, 127; beet, 129: cane. 129; 
in fruits, 175; maple. 129: milk, 
131; substitutes for, 679: urine and, 
128. 

Sulphates, 48. 

Sulphur, 48; waters, 209. 

Summer diarrhoea, 557. 

Superalimentation, 464, 613. 

Suppositories, food, 410. 

Suralimentation, 464, 613. 

Surgical patients, diet for, 695. 

Sweet bread, 121. 

Sweet potatoes, 167. 

Swiss cheese, 100. 

Swiss milk. 94. 

Syntonin, 349. 

Tabasco. 257. 

Taenia, 369. 

Taka-diastase, 353. 

Tamarinds, 181. 

Tannin, 210. 

Tapeworm. 369. 

Tapioca, 157. 

Tea, 211; adulteration. 215: black, 
211; beef, 802; coffee compared 
and, 220: good effects of, 212; 
green, 211; habit, 214; ill effects, 
214; infusion, 212; properties, 212. 

Teething and food, 768. 

Temperature and digestion, 333; food 
and, 284, 333-336. 

Test meals, 515. 

Tetanus, 453. 

Theobromine. 222. 

Thirst, 43. 404; in fever. 430. 

Thyroid gland. 121. 

Tin poisoning. 384. 

Toast, 143. 

Tobacco, 575: food and. 360. 

Tomatoes, 171. 

Tongue, 119. 

Tonsilitis, 508. 

Tous-les-mois, 157. 

Tracheotomy, 444. 

Training, 727, 734. 

Travel, diet in, 743. 

Treacle. 131. 

Trichina spiralis, 370. 

Trichinosis, 370; symptoms. 372. 

Tripe, 122. 

Trommer's diastatic extract of malt. 
160. 

Tropon, 112. 



Truffles, 189. 

Tubercular laryngitis, 468. 

Tuberculosis, 455; aids to dietetic 
treatment, 466; diet in advanced 
cases, 462; diet in mild cases, 460; 
forced feeding and. 464; milk and, 
64, 386; meat and, 386. 

Tubers. 165, 168. 

Tufnell's diet, 483. 

Turkey, 121. 

Turnips, 168. 

Typhoid fever, 425; children in, 437: 
convalescent diet, 435; milk diet in, 
426; and milk, 66; milk infection 
and, 388; oysters and, 388: pathol- 
ogy. 425- 

Typhus fever, 437. 

Tyrotoxicon, 378. 

Ulcer of the stomach. 546. 

United States Army Hospital dieta- 
ries, 793-797; prison diet, 713; ra- 
tions, 701-707; navy ration. 710. 

Uric-acid diathesis, 504. 

Urine and food, 360-489: and fruits. 
176; diabetic, 663. 

Urinary system, 489. 

Urticaria, 615. 

Utica State Hospital dietaries, 791. 

Valentine's meat juice, 117. 

Valvular heart disease, 477; in chil- 
dren, 478. 

A^anilla, 257. 

Variola, 438. 

Veal, 119. 

Vegetable and animal food compared. 
29-35: acids, 48; fats, 197; food. 5, 
160; marrow, 173; oils, 197. 

Vegetables, composition of, 173; 
cooking of, 269; dried. 211: green, 
169. 

Vegetarianism. 30. 31. 35-37. 

Venison. 119. 

Vermicelli, 152. 

Vertigo. 605. 

Vichy, 209. 

Vinegar. 257. 

Viscera. 121. 

Vomiting. 543; of pregnancy, 546. 

Walnuts. 190. 

Water, 18. 37; acidulous, 210; boiled, 

41: chalybeate. 210; in constipation. 

573: in diabetes, 680; distilled. 40; 



828 



INDEX 



excess of, 42; in fevers, 420; fil- 
tered, 40; in gout, 650; hard, 39; 
lime, 807; mineral, 207; quantity 
required, 37, 292; purity of, 38; 
rain, 39; river, 40; soft, 39; starva- 
tion, 43; thermal, 208; uses, in 

. body, 38; varieties of, 39. 

Watermelons, 187. 

Waters, alkaline, 207, 209; efferves- 
cing, 207; purgative, 210; sulphur, 
209. 

Weaning, 755. 

Weight and food, 312. 

Weir Mitchell's system, 632. 

Welsh rarebit, 100. 

Wet nurse, 746-748. 

Wheatena, 150. 

Wheaten flour, 142. 

Wheat kernel, structure of, 135. 

Whey, 99. 101; cure, 721. 

Whisky, 250. 

White pepper, 255. 

Whooping-cough, 440. 



Wine, 241; cocoa, 246; composition 
of, 241; fig, 251; properties of, 242; 
raisin, 249. 

Wines, adulteration of, 251; acid, 
246; aromatic, 246; digestion and, 
249; dry, 245; "perfect," 248; red, 
244; Rhine, 246; rough, 249; spark- 
ling, 246; sweet, 246; white, 243; 
varieties of, 245. 

Woodcock, 121. 

Work, food and, 15; foot pounds 
and, 12; ration, 17. 

Worms, intestinal, 369. 

Yale boat crew dietary, 729; football 

dietary, 733. 
Yam, 167. 
Yeast, 138. 

Yellow fever, 449-452. 
Yeo system, 633. 

Zoolak, 83. 
Zwieback, 144. 



(1) 



THE END 



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